Coma

Coma: Excerpt from In A Page: Pediatric Signs and Symptoms

Coma is a state of total unawareness of the self and the environment. There is no eye opening or response to voice or painful stimuli. Coma can be due to dysfunction of either bilateral cerebral cortex or the reticular activating system in the brainstem or both combined. Locating the lesion is very helpful in determining the etiology and thus the management.

Differential Diagnosis

• Infection
  –Meningitis/encephalitis
  –Bacteria, virus, fungi, spirochete
• Increased intracranial pressure
  –Tumor, abscess, hydrocephalus
• Vascular
  –Intracranial hemorrhage, stroke
  –Hypoxic ischemic injury (hypotension, cardiac arrest, arrhythmia, near-drowning)
  –Vasculitis
• Toxins
  –Uremia, ethanol, atropine, opiates, lead, substance abuse
• Trauma: Concussion, contusion
• Seizure
  –Nonconvulsive status epilepticus
  –Postconvulsive state (postictal state)
• Electrolyte imbalance
  –Hyponatremia, hypernatremia
  –Hypomagnesimia
  –Hypoglycemia, hyperglycemia
  –Hypercalcemia, hypocalcemia
• Postinfectious
  –Acute disseminated encephalomyelitis (ADEM)
• Endocrine disorders
  –Adrenal insufficiency
  –Thyroid disorders
• Degenerative and metabolic diseases
  –Urea cycle disorders
  –Reye syndrome
  –Mitochondrial disease
• Systemic infection and sepsis
• Hepatic encephalopathy
• Psychogenic
  The mnemonic AEIOU-TIPS has been used to recall portions of the differential diagnosis:
  Alcohol ingestion and acidosis
  Epilepsy and encephalopathy
  Infection
  Opiates
  Uremia
  Trauma
  Insulin overdose or inflammatory disorders
  Poisoning and psychogenic causes
  Shock

Workup and Diagnosis

• History
  –Trauma, seizures, diabetes; cardiac, liver, renal disease
  –Presence of delirium before the onset of coma
  –Fever, neck stiffness, headache
  –Possible toxins at home
• Physical exam
  –Vital signs, temperature
  –Pattern of breathing (Cheyne-Stokes, apneustic, ataxic)
  –Retinal hemorrhages, otorrhea, spinal fluid rhinorrhea
  –Thyroid, cardiac rhythm, murmur
  –Skin (cyanosis, petechiae, splinter hemorrhages)
  –Hepatosplenomegaly, meningismus
• Neuro exam: Response to voice and noxious stimulation
  –Papilledema, pupillary size, and light reflex
  –Eye movements (spontaneous, doll's, calorics), corneals
  –Gag, motor response to pain, DTRs, Babinski
  –Decerebrate or decorticate posturing, muscle tone
• Labs
  –Toxicology screen, glucose, electrolyes
  –CBC, ABG, LFT, ammonia
  –BUN, creatinine, TSH, blood culture
• Studies
  –Neuroimaging: CT or MRI
  –Lumbar puncture (after herniation has been ruled out)
        –If subarachnoid hemorrhage or infection is suspected
  –EEG to rule out nonconvulsive status epilepticus, gives clues to a metabolic process (triphasic waves)

Treatment

• First assess airway, breathing, and circulation (ABCs)
  –Obtain intravenous access
  –Treat for hypoglycemia
  –Look for signs of herniation and increased ICP
• Reverse toxins if possible: Naloxone for opioids
• Treat with antibiotics for possible infectious agents
  –Cephalosporins (for bacteria), acyclovir (for herpes)
• Increased intracranial pressure (ICP)
  –Keep head of the bed up
  –Intubate and hyperventilate
  –Give mannitol (an osmotic agent)
• Seizures: Treat with benzodiazepines and fosphenytoin
• Treat the underlying systemic illness
• Observe in the intensive care unit with frequent neurologic examinations
  –Closely observe fluid status, changes in temperature
  –Prevent iatrogenic problems (e.g., DVT, corneal abrasions, decubitus ulcers)

Book Source Details

• Book Title: In A Page: Pediatric Signs and Symptoms
• Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
• Year of Publication: 2007
• Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

More About Persistent Vegetative State

• Back to disease: Persistent Vegetative State: Introduction
• Next Book Extract About Persistent Vegetative State: COMA AND SOMNOLENCE (Differential Diagnosis in Primary Care)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: In A Page: Pediatric Signs and Symptoms Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-4051-0427-9

 » Next page: COMA AND SOMNOLENCE (Differential Diagnosis in Primary Care)

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