May / 2018 PELC / SLCP 1 CHILD IN NON - TRAUMATIC COMA PELS
May / 2018 PELC / SLCP 2 Objectives Recognize depressed mental status Know the causes of depressed mental status in children Assessment and workup for depressed mental status in children Initiate management of depressed mental status in children Raised ICP and neuropretection
May / 2018 PELC / SLCP 3 Case History A five-year-old boy is brought to the A&E department with vomiting and fever for 5 days. The parents describe child has been getting drowsy and had generalised convulsion 4 hours back and not recovered well. He is now drowsy and lethargic. Guide weight 20kg. RR 25/bpm, Pulse rate 70/min, BP-100/90, Pupils midway slow to react, Decorticated position
May / 2018 PELC / SLCP 4 Problems identified GCS is low Raised ICP signs? Working diagnosis Primary survey & Initial stabilization? LP? Specific Treatment
May / 2018 PELC / SLCP 5 What do you do? BLUE PRINT
May / 2018 PELC / SLCP 6 PELS Approach Reassess again The Blueprint Triage Initial Stabilisation Position Airway Breathing Circulation Disability Measurement Monitoring Reassess Directed History and Examination and Ix Reassess Commence Specific Treatment Ongoing Care THEN?
May / 2018 PELC / SLCP 7 Airway & Breathing Open and maintain airway Position Sniffing position Airway opening maneuvers Head tilt & chin lift / Jaw thrust Clear the obstruction Suck out secretions Oral airway High-flow oxygen with reservoir bag
May / 2018 PELC / SLCP 8 Circulation Pulse rate & volume, CRFT, BP IV access RBS, BC, FBC, Clotted sample Maintain Mean arterial BP Fluid (Normal maintenance) & Inotropes Catheterize the patient and check urine output.
May / 2018 PELC / SLCP 9 Maintain cerebral perfusion pressure CPP = MAP ICP
May / 2018 PELC / SLCP 10 Initial Stabilisation Disability GCS Conscious level Posture - Pupils - Posture Pupillary signs
May / 2018 PELC / SLCP 11 Eye Opening 4-Spontaneously 3-To Speech 2-To Pain 1-None Best Verbal Response 5-Orientated 4-Confused 3-Inappropriate words 2-Incomprehensible sounds 1-None Best Motor Response 6-Obeys commands 5-Localizes to pain 4-Withdraws from pain 3-Abnormal flexion 2-Abnormal extension 1-None
May / 2018 PELC / SLCP 12 Stage 2: INITIAL STABILISATION DISABILITY (simultaneous assessment + treatment) Conscious level Posture Decorticated / Decerbrated Posture Pupillary signs Pupils Equal / Unequal / reacting / non-reacting / size
May / 2018 PELC / SLCP 13 What are the abnormal postures?
May / 2018 PELC / SLCP 14 Initial Stabilisation Measure and Monitor Measure BSL Correct Temp Monitor ECG BP SaO 2
May / 2018 PELC / SLCP 15?? Working Diagnosis
May / 2018 PELC / SLCP 16 Treat treatable Low blood sugar Correct blood sugar Meningitis Cefotaxime / Cefriaxone Dexamethazone 0.15mg/kg bid X 2days Herpes Encephalitis Acyclovir Krait bite / Snake bite : Antidote +/- IPPV Hypertensive encephalopathy : control BP
May / 2018 PELC / SLCP 17 Treat treatable DKA : Follow the protocol Poisoning :Antidotes Metabolic abnormalities : Appropriate investigations Cerebral Malaria Quinine IV Mycoplsma Encephalitis Clarithromycin IV Bleeding / Blood clots : Correction of clotting profile Surgical intervention
May / 2018 PELC / SLCP 18 Directed History Last meal H/O Fever, vomiting, drowsiness Focal fits Sleeping on the floor snakes Early morning headaches, urinary problems Polyuria, recent weight loss Accidental ingestion Recent travel Recent accidental fall / Trauma On medication anti-clotting effects P/H of meningitis
May / 2018 PELC / SLCP 19 EARS & NOSE: CSF leakage bleeding SKIN: rash clammy temperature cyanosis bruising evidence of trauma BREATHING PATTERNS: hyperventilation Cheyne-Stokes breathing Apnoea Effort, efficacy, effect POSTURE: floppy decorticate decerebrate Reassessment - Neurological examination PUPILS ABDOMEN: bruising distension rigidity
May / 2018 PELC / SLCP 20 Raised intra cranial pressure Relative signs Previously well & deteriorating LOC with GGCS <9 Abnormal breathing patterns Abnormal posture Decorticate posture Decerebrate Cushing s triad Hypertension Slow pulse Abnormal breathing patterns
May / 2018 PELC / SLCP 21 Raised intra cranial pressure Relative signs Eye Examination Altered pupil size and reactivity Abnormal oculocephalic reflexes (Dolls eye movement; conjugate up gaze, side gaze) Avoid in patients with suspected neck injuries Ophthalmoplegia lateral or vertical deviation Loss of his conjugate upward gaze. Avoid in patients with suspected neck injuries
May / 2018 PELC / SLCP 22 Look for raised ICP signs Absolute signs Absence of venous pulsation in retinal vessels. Papilloedema Bulging Fontanelle (under 18 months) All these three signs are absent in acutely raised ICP
May / 2018 PELC / SLCP 23 Investigations Venous blood sugar FBC & Blood picture CRP & ESR Blood culture SE, Ca+ Lumbar puncture Nasopharngeal culture Venous blood gas Live profile Renal profile Clotted sample
May / 2018 PELC / SLCP 24 Decreased conscious level Contra-indications for LP Haemodymic instability Raised ICP Focal neurological signs
May / 2018 PELC / SLCP 25 Medical Management IV Fluids to maintain MAP Anti- meningitis dose of antibiotics Anti-viral therapy
May / 2018 PELC / SLCP 26 Place of Neuro-imaging USS CT MRI
May / 2018 PELC / SLCP 27 Neuroprotection in Raised ICP General Principles Head tilt to 20-30º degrees Free of disturbances No noises Gentle suction Safe intubation Dark environment Drugs / Sedation
May / 2018 PELC / SLCP 28 Neuroprotection in Raised ICP General Principles Hypoglycaemia Tight glycaemic control 4-7 mmol/l Electrolytes normalise Convulsions anticonvulsants Hyperthermia Brain cooling
May / 2018 PELC / SLCP 29 Emergency Management of raised ICP Intubate and support ventilation Maintain normal oxygenation Maintain CO2 : 30-35 mmhg/4-4.5 kpa Support Circulation Osmotherapy Manitol 3% Sodium Chloride Consider surgery Flap removal
May / 2018 PELC / SLCP 30 Q & A Summary
May / 2018 PELC / SLCP 31 History and clinical findings thorough clinical assessment can narrow down dd History & Examine for possible cause Maintain MAP Consider osmotherpay & Surgical option
May / 2018 PELC / SLCP 32