Coma :

A state of unrousability
The changes in mental state which precede coma may
be classified by the Modified Glasgow Coma Scale For
Infants And Young children

Need Emergency Care

 Consciousnessis a state conscious of her /
himself and environment

Coma is a state of total self-

unconsciousness and environment even
stimulated by a strong stimulation
Full consciousness :
Responsive to her / himself and environment

Consciousness is controlled by the hemisphere and ARAS

 The damage of brain stem/ formatioreticularis:
rapidly/directly decreased of consciusness coma

The damage of cerebral cortex (> 2/3 extensive of

damage)
LEVEL OF CONSCIOUSNESS

Compos mentis

Apathetic

Somnolene

Stupor

Coma
CAUSES
Cerebral Hypoxaemia/ischaemia
Severe anemia, apnoea, asphyxiation, carbon
monoxide poisoning, drowning, respiratory
failure, shock (adrenal crisis, cardiogenic, septic,
hypovolaemic), cerebrovascular event.
Ischemic brain injury after failing breath and
circulation
 Epilepsy

Post-ictal state, status epilepticus

Infectious disease

Encephalitis, meningitis, septic shock

 Metabolic and endocrine disorders

Diabetic ketoacidosis, hypoglycaemia,

hypernatremia, hyponatremia, hypocalcaemia,
hypomagnesaemia, liver failure, renal
failure(uremia).
 Toxic
Substance abuse (alcohol, hallucinogens, opiates, volatile
agents), clonidine, paracetamol, prescription drugs,
salicylates, lead, other

Trauma
Concussion, cerebral contusion, intracranial
haemorrhage, cerebral oedema (remember shaken infant
syndrome)

Other
Acute confusional migraine, psychiatric
DIAGNOSIS
Diagnosis is supported by:
Anamnesis/History

Phisical and neurological examination

Glasgow coma scale

Vital sign

Breathing pattern

Pupil

Eye movement

Motoric
HISTORY

Time course of changes in mental state (behavior,

feeding, schoolwork)
Past and recent medical history (including
medications)
Family history (for example, of epilepsy or
migraine)
Drugs or toxins present in the house

History of head trauma

 PHYSICAL AND
NEUROLOGICAL EXAMINATION

Glasgow Coma Scale (GCS)

Systemic: vital sign (breathing pattern, cardiac

rhythm, blood preassure, pulse)

Neurological: cranialis nerve, eye movement,

pupil, funduscopy

Motoric: paralysis
 Glasgow Coma Scale

Category Response Response > Score

< 1 year 1 year
Eye opening Spontaneous Spontaneous 4
To shout To speech 3
To pain To pain 2
None None 1

Best motor Normal movement Obeys command 6

responese Localizes pain Localized pain 5
Flexion withdrawl1 Flexion withdrawl 4
Flexion-abnormal Flexion-abnormal 3
(decorticate) (decorticate)
Extension Extension 2
(decerebrate) (decerebrate)
none none 1

1apply knuckles to sternum and observe

arms
 0-23 months 2-5 years >5 years
Best verbal 5 Smiles/cries/ Appropriate orientated
response2 appropriate words/
phrases
4 Cries/screams Inappropriate Confused
words response
3 Irritable/inconsolable Cries/screams Inappropriate
words
2 Grunts/agitated grunts Incomprehen-
sible
1 none none none

2 arouse patient with painful stimulus if necessary

In these scale, the total score = eye opening + motor response + verbal
response. The best response is scored. The lowest score is 3, and the
highest is 15 (the fully conscious child)

Children in coma have GCS scores of 8 or less. In the context of head

trauma, a GCS of 8 or less suggests severe cerebral injury, a GCS of 9
12 moderate cerebral injury, and a GCS of 13 15 minor cerebral injury

Limitations of the GCS include the fact that the verbal component is
difficult to apply to young children and cannot be applied to the intubated
patient. The score does not give any weight to focal deficits such as
hemiparesis. The score was developed in adults, and does not have the
same predictive value in childhood
Examination Of GCS (Eye Opening)

Spontaneous = 4 Response to speech = 3

EXAMINATION OF GCS
(BEST MOTOR RESPONSE)

Obeys = 6

Localizes = 5

Withdraws = 4
EXAMINATION OF GCS
(BEST VERBAL RESPONSE)

Oriented = 5

Confused
conversation = 4
INTERPRETATION GCS
Open Eyes (E), maximal score :4
Verbal (V), maximal score :5
Motoric (M), maximal score :6

Interpretation :
Mild coma GCS : 12-14
Moderate coma GCS : 9- 11
Severe coma GCS : <8
VITAL SIGN

Blood presure:
High pressure: increase of intracranial pressure,
intoxication
Low pressure: Shock, bleeding

Irregular heart rhythm:

- Amfetamin
- Digitalis
- Antikolinergik

Bradikardi: Takikardi:
- Narkoti - Alkohol
- Beta bloker - Amfetamin
BREATHING PATTERN
a. Cheyne Stokes
Apnue hiperpnue:
Bilateral cerebral disorder,
diensefalon, herniasi

b. Hiperventilasi
quick and under :
- midbrain disorder
- metabolic asidosis, hypoxia, toxicity

c. Apneuristic
Pons disorder

d. Ataksik / Apnea
no breathing pattern, damage in the
medula oblongata
PUPILLARY CHANGES (LOCATE OF LESION)
Size and reaction of pupil Causes
Small reaction metabolic disorder
lesion of medula

Fix and pinpoint metabolic disorder

narcotic poisoning/
barbiturat /organofosfat
Fix medium Lesion Mid brain

Fix dilatation Hypotermia

SevereHypoksia
Barbiturat (advanced
symptom)

Unilateral fix dilatation Herniasi tentorial

Lesion N III
REFLECT OF PUPIL
 AbN AbN
AbN/- N/+

N N N
AbN

Lesion of N.Optikus (D) Lesion of N.Occulomotorius (D)

DOLLS EYE MOVEMENT
Motoric examination :
Hemipharese : UMN disorder, contralateral lesion
Decortication : Spinalis tract disorder
Deserebration : Vestibulospinalis tract disorder

Opistotonus :
severe damage to both hemispheres
 LOCATE OF LESION
It is difficult differentiate supratentorial from
infratentorial lesions unless localising brainstem signs
precede the onset of coma

Breathing Pattern Pupil DEM Locate of lesion

Cheyne stoke myosis +/+ Cortex
Chussmaul Mydriasis +/- Midbrain
Hyperventilation RC (+)

Ataksic Pin point -/ - Pons

Apnue Dilatation -/- M. Oblongata
CLINICAL MANIFESTATION AND
LOCATE OF LESION
FURTHER INVESTIGATIONS
FBC Consider coagulation screen
Glocose
Urea and Electrolytes
Blodd Gas
Urinalysis Consider toxicology
Liver Fuction tests Consider serum ammonia
Lumbar Puncture Contraindicate GCS <8,
raised ICP or unstable
clinical state. If
meningitis is susp but LP
C.IndicStart AB
CT head Bleeding, trauma
MRI Brainstem
EEG
MANAGEMENT

Airway

Protect and maintain. Use airway adjunt

(oropharyngeal, nasopharyngeal) or unable to maintain
airway. If GCS < 8 and clinical circumstances do not
suggest improvement imminent then intubation is
indicated to secure airway
 Breathing
Give oxygen until saturation known,
monitor O2 saturation, assess rate and
pattern of breathing

Circulation
Obtain venous access. Assess for signs of
shock and treat as indicated. The aim of
fluid therapy in raised ICP is to maintain
adequate cerebral perfusion pressure
(CPP)
 Dextrose
Aim to avoid both hyper and hypoglicaemia.
Check blood glucose level :

If low take blood for hormones (insulin, hGH,

cortisol) and ketones and give a bolus of 10%
Dextrose 5 ml/kg IV, followed by a 10% Dextrose
infusion at 4 ml/kg/hour (7mg/kg/min) with close
monitoring of glucose

If high consider diabetes

 Drugs
If opiates suspected, consider Naloxone 0,1 0,8 mg/kg
IV (maximum dose 2 mg) particularly if respiratory
depression

Electrolyte Imbalance: natrium, magnesium

 Specific therapy

After stabilisation a rapid approach to

diagnosis is imperative so that specific therapy
can be given

Acyclovir and cefotaxime should be

administered acutely if encephalitis or
meningitis is a possibility
EMERGENCY MANAGEMENT OF RAISED
INTRACRANIAL PRESSURE

i.e GCS < 8 and Cushings triad of hypertension,

bradycardia, abnormal respiration (gasping,
irregular, sporadic) and/ or fixed, dilated pupil
(s)

Airway oxygenate and intubate

Ventilate avoid hypercapnoea.

 Osmotic therapy
use 3% NaCl give 3ml/kg IV given as a rapid
infusion (e.g. over 5 to 10 minutes) or
Use mannitol 0,5 g to 1,0 g/kg (2,5 to 5 ml/kg of
20% Mannitol)
Will need to place a urinary catheter
 Sedation and pain relief for example
morphine and midazolam

Elevated head to 30

Control fever give paracetamol

intragastrically or rectally 10 15 mg/kg q 4 hrly
TATA LAKSANA ANAK TIDAK SADAR
Jalan napas- intubasi bila GCS <3
Pernapasan- SaO2>80%

Sirkulasi- Tekanan nadi >70 mmHg

Lab darah tepi, AGD, fs hati dll

Pemeriksaan Neurologis
TIK naik Manitol, Glu <60mg%- beri Glu, koreksi
ganguan elekt, awasi keracunan

CT scan /MRI

Evaluasi ulang (Riwayat lengkap, pem sistemik)

LP, EEG
PROGNOSIS
90% recovered with perfectly
Mortality of coma is 25%, usually caused by
encephalytis
Coma non traumatic 50% recovered ferfecly, 30%
death, 20% to be invalid
Coma metabolic 50-75 recovery/minimal invalid
Thank You