Pediatric Emergency (Coma) PDF

 What Is a Coma? A coma is a medical emergency defined as a prolonged state of unconsciousness that can be caused by a variety of problems. During a coma, a person is unresponsive to their environment. The person is alive and looks like they are sleeping. However, unlike in a deep sl...

 What Is a Coma? A coma is a medical emergency defined as a prolonged state of unconsciousness that can be caused by a variety of problems. During a coma, a person is unresponsive to their environment. The person is alive and looks like they are sleeping. However, unlike in a deep sleep, the person cannot be awakened by any stimulation. What Causes a Coma? Comas are caused by an injury to the brain. Brain injury can be due to increased pressure, bleeding, loss of oxygen, or buildup of toxins. The injury can be temporary and reversible. It also can be permanent.  More than 50% of comas are related to head trauma or disturbances in the brain's circulatory system. Problems that can lead to coma include:  Anoxic brain injury: ØThis is a brain condition caused by total lack of oxygen to the brain. ØLack of oxygen for a few minutes causes cell death to brain tissues. ØAnoxic brain injury may result from heart attack (cardiac arrest), head injury or trauma, drowning (inhale water), drug overdose, or poisoning.  Trauma: ØHead injuries can cause the brain to swell and/or bleed. ØWhen the brain swells as a result of trauma, the fluid pushes up against the skull. ØThe swelling may eventually cause the brain to push down on the brain stem, which can damage the RAS (Reticular Activating System) -- a part of the brain that's responsible for arousal and awareness.  Swelling: ØSwelling of brain tissue can occur even without distress. ØSometimes a lack of oxygen, electrolyte imbalance, or hormones can cause swelling.  Bleeding: ØBleeding in the layers of the brain may cause coma due to swelling and compression on the injured side of the brain. ØThis compression causes the brain to shift, causing damage to the brainstem and the RAS. ØHigh blood pressure, ruptured cerebral aneurysms, and tumors are non-traumatic causes of bleeding in the brain.  Stroke: ØWhen there is no blood flow to a major part of the brain or loss of blood accompanied with swelling, coma can occur.  Blood sugar: ØIn people with diabetes, coma can occur when blood sugar levels stay very high. That's a condition known as hyperglycemia. ØHypoglycemia, or blood sugar that's too low, can also lead to a coma. ØThis type of coma is usually reversible once the blood sugar is corrected. ØHowever, prolonged hypoglycemia can lead to permanent brain damage and persistent coma.  Oxygen deprivation: ØOxygen is essential for brain function. ØCardiac arrest causes a sudden cutoff of blood flow and oxygen to the brain, called hypoxia or anoxia. ØAfter cardiopulmonary resuscitation (CPR), survivors of cardiac arrest are often in comas. Oxygen deprivation can also occur with drowning or choking (fight for breath).  Infection: ØInfections of the central nervous system, such as meningitis or encephalitis, can also cause coma.  Toxins: ØSubstances that are normally found in the body can accumulate to toxic levels if the body fails to dispose of them correctly. ØAs an example, ammonia due to liver disease, carbon dioxide from a severe asthma attack, or urea from kidney failure can accumulate to toxic levels in the body. ØDrugs and alcohol in large quantities can also disrupt neuron functioning in the brain.  Seizures: ØA single seizure rarely produces coma. ØBut continuous seizures -- called status epilepticus -- can. ØRepeated seizures can prevent the brain from recovering in between seizures. ØThis will cause prolonged unconsciousness and coma.  The GCS (Glasgow Coma Scale) is the summation of scores for eye, verbal, and motor responses. The minimum score is a 3 which indicates deep coma or a brain-dead state. The maximum is 15 which indicates a fully awake patient (the original maximum was 14, but the score has since been modified). ***A GCS of 8 or less indicates severe injury, one of 9-12 moderate injury, and a GCS score of 13-15 is obtained when the injury is minor. Types of Coma? Types of coma can include: vToxic-metabolic encephalopathy. § This is an acute condition of brain dysfunction with symptoms of confusion and/or delirium. § The condition is usually reversible. The causes of toxic-metabolic encephalopathy are varied. § They include systemic illness, infection, organ failure, and other conditions. vPersistent vegetative state. This is a state of severe unconsciousness. The person is unaware of their surroundings and incapable of voluntary movement. With a persistent vegetative state, someone may progress to wakefulness but with no higher brain function. With persistent vegetative state, there is breathing, circulation, and sleep-wake cycles. vMedically induced: This type of temporary coma, or deep state of unconsciousness, is used to protect the brain from swelling after an injury - and allow the body to heal. The patient receives a controlled dose of an anesthetic, which causes lack of feeling or awareness. Doctors then closely watch the person’s vitals. This happens only in hospital intensive care units. Symptoms The signs and symptoms of a coma commonly include: Closed eyes Depressed brainstem reflexes, such as pupils not responding to light No responses of limbs No response to painful stimuli Irregular breathing Diagnosis Because people in a coma can't express themselves, doctors must rely on physical clues and information provided by families and friends. Be prepared to provide information about the affected person, including:  Events leading up to the coma, such as vomiting or headaches Details about how the affected person lost consciousness, including whether it occurred suddenly or over time Noticeable signs or symptoms before losing consciousness The affected person's medical history, including other conditions he or she may have had in the past, such as a stroke or transient ischemic attacks Recent changes in the affected person's health or behavior The affected person's drug use Physical exam The exam is likely to include: Checking the affected person's movements and reflexes, response to painful stimuli, and pupil size Observing breathing patterns to help diagnose the cause of the coma Checking the skin for signs of bruises due to trauma Speaking loudly or pressing on the angle of the jaw or nail bed while watching for signs of arousal, such as vocal noises, eyes opening or movement Testing reflexive eye movements to help determine the cause of the coma and the location of brain damage Squirting cold or warm into the affected person's ear canals and observing eye reactions Laboratory tests Blood samples will be taken to check for: Complete blood count Electrolytes, glucose, thyroid, kidney and liver function Carbon monoxide poisoning Drug or alcohol overdose A spinal tap (lumbar puncture) can check for signs of infections in the nervous system. Brain scans Imaging tests help doctors pinpoint areas of brain injury. Tests might include: CT scan. This uses a series of X-rays to create a detailed image of the brain. A CT scan can show a brain hemorrhage, tumors, strokes and other conditions. This test is often used to diagnose and determine the cause of a coma. MRI. This uses powerful radio waves and magnets to create a detailed view of the brain. An MRI can detect brain tissue damaged by an ischemic stroke, brain hemorrhages and other conditions. MRI scans are particularly useful for examining the brainstem and deep brain structures. Electroencephalography (EEG). This measures the electrical activity inside the brain through small electrodes attached to the scalp. Doctors send a low electrical current through the electrodes, which record the brain's electrical impulses. This test can determine if seizures might be the cause of a coma. Treatment for a Coma? Treatment for a coma depends on the cause. People close to the comatose patient should give doctors as much information as possible to help the doctors determine the cause of coma. Prompt medical attention is vital to treat potentially reversible conditions. For example, if there is an infection that's affecting the brain, antibiotics may be needed. Glucose may be required in the event of a diabetic shock. Surgery may also be necessary to relieve the pressure on the brain due to swelling or to remove a tumor.  Certain drugs may also help relieve the swelling. Medication may also be given to stop seizures if necessary. People in comas are looked after in an intensive care unit and may often require full life support until their situation improves. Complications Although many people gradually recover from a coma, others enter a vegetative state or die. Some people who recover from a coma end up with major or minor disabilities. Complications can develop during a coma, including pressure sores, urinary tract infections, blood clots in the legs and other problems. THANK YOU