DIAH MUSTIKA HW SpS-KIC

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As a medical emergency, coma presents a challenge to providers because optimal care requires timely intervention; however, information is frequently limited during the initial evaluation.

(Pearson-Shaver and Mehta, Pediatric Critical Care Medicine Textbook, 2007, p. 855)

Mental Status
Consciousness is a condition in which an individual is fully responsive to stimuli and demonstrates awareness of the environment An alteration in mental status is the hallmark sign of central nervous system (CNS) injury or illness

Mental Status
EMTs evaluate mental status in two ways:

Responsiveness- how does a patient

respond to external stimuli Orientation- checks the patients memory and thinking ability

Mental Status
Responsiveness is assessed using the AVPU mnemonic. Alert- patients eyes are open spontaneously without stimuli. Verbal- patients eyes open when spoken to. Painful- patient responds to a painful stimuli in some way (i.e. cries, withdraws, etc). Unresponsive- patient does not respond spontaneously to any stimuli.

Mental Status
Orientation is how the patient responds verbally. This evaluates the patients ability to think and test their memory. The 4 common questions used to evaluate this are: Person- their name Place- where are they Time- year, month, and approximate date Events- what happened

What is consciousness?
state of wakefulness and awareness of self and surroundings
(Abend et al., Rogers Handbook of Pediatric Intensive Care Medicine, 2009, p. 256)

Neural processes that allow for patient to:

Perceive Comprehend Act on the internal and external environment

Two neurophysiologic functions:

Arousal Awareness

Levels of Arousal:
Alert: Fully conscious Lethargic: appear somnolent, but may be able to maintain

arousal spontaneously or with repeated light stimulation

Obtunded: requires touch or voice to maintain arousal Stuporous: unresponsiveness from which the individual can

be aroused only by vigorous and repeated stimulus

Comatose: state of unarousable unresponsiveness in which

individual lies with eyes closed, lacking awareness of self

and environment

Motor Response Commands Localizes Pain Withdraws from Pain Abnormal Flexion Abnormal Extension

Example Follows simple commands Pulls examiner's hand away when pinched Pulls a part of body away when pinched Flexes body inappropriately to pain Body becomes rigid in an extended position when examiner pinches him

Score 6 5 4 3

2 1

No Response Has no motor response to pinch

Eye-Opening EyeSpontaneous Opens eyes on own Opens eyes when asked to To Voice in a loud voice To Pain Opens eyes when pinched No Response Does not open eyes

. 4 3 2 1

Verbal Response (Talking) Carries on a conversation correctly and tells examiner where he is, who he is, and Orientated the month and year Confused Seems confused or Conversation disoriented Talks so examiner can understand him but makes Inappropriate Words no sense Makes sounds that Sounds examiner cannot understand No Response Makes no noise

5 4

3 2 1

Coma Scales for Children Activity Infants Children

Eye Opening
Spontaneous To speech To pain None Spontaneous To verbal stimuli To pain None Oriented Confused Inappropriate words Nonspecific words None Follows commands Localizes to pain Withdraws to pain Flexion to pain Extension to pain None

Score
4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Verbal

Coos, babbles Irritable, cries Cries to pain Moans to pain None

Motor

Normal movements Withdraws to touch Withdraws to pain Abnormal flexion Abnormal extension None

Pathophysiology:
Consciousness depends on proper function of both

cerebral hemispheres and the reticular activating system (RAS)

Normal function requires
Adequate substrate (primarily glucose) Cofactors Waste removal Adequate blood flow needed for delivery/removal

Roads to coma
Increased neuronal excitability Restless/Confusion Tremor/Delirium

Stupor Coma

Decreased neuronal excitability Lethargic Obtunded

Stabilization:

Stabilization:
Airway
Assess for patency Assess for ability to protect

Breathing
Assess ventilation Assess breathing pattern

Circulation
Assess measures of cardiac output

Stabilization:
D = Da brain Decision point

Concern for increased ICP

No concern for increased ICP

Stabilization:
Increased ICP Must act immediately

No increased ICP Time to consider your workup

Evaluation:
History Physical Exam Laboratory and Imaging Studies

EvaluationHistory:
Rapid initial history:
Recent history prior to mental status changes Past medical history (seizures) Family history (specifically seizures/neurologic disorders) Trauma ? Febrile ? / Other signs or symptoms of infection Diet Exposure to drugs/toxins

Follow-up with more complete history:

EvaluationPhysical Exam:
Systemic Vital Signs Signs of trauma Signs of infection Signs of bleeding Signs of other systemic illnesses

EvaluationPhysical Exam:
Rapid Neurologic Exam: Pupils Respiratory pattern Stimuli needed to elicit response Character of the response

Neurologic ExamPupils:

Respiratory patterns:
Location
Hemispheric Midbrain Mid/Lower Pons Low Pons/Upper Medulla Medulla

Pattern
Cheyne-Stokes Central Hyperventilation Apneustic Cluster breathing/Gasping Agonal breathing

Posturing:

Decorticate lesion above midbrain

Decerebrate lesion below midbrain

EtiologiesDifferential by Age:
Infant Infection Inborn Error of Metabolism Metabolic Abuse Trauma Child Adolescent Ingestion Ingestion Intentional Infection Trauma Intussusception Drug/Alcohol Seizure overdose Abuse Trauma

(Pearson-Shaver & Mehta in Pediatric Critical Care Medicine Textbook, 2007, p. 857)

Summary:
Coma is altered consciousness with loss of arousal and awareness Stabilization
ABCs Decide about increased ICP

Evaluation
Rapid history and physical Rapid Neuro ExamPupils, Resp Pattern, Stimuli and Response

Etiologies

Toxic/Metabolic Infectious Structural/Intrinsic Paroxsymal

QUESTIONS?