Non-traumatic Coma In Children Research Articles

Non-Traumatic Coma in Children- A Review

Coma is defined as the unintentional failure of the patient to open their eyes spontaneously or in response to noise and inability to open for commands or localised painful stimuli with or without the ability to express comprehensible words or language response, whereas the Non traumatic coma is without any injury to the brain, and the Glasgow coma scale below 12. The Non traumatic coma causes due to the infections(tubercular meningitis, bacterial meningitis, encephalitis) and other metabolic conditions ,status epilepticus intracranial bleed, miscellaneous, hypoxic ischemic insults, Electrical shock, shunt dysfunction, Inborn error of metabolism. The monitoring parameters are Heart rate, Respiratory rate and pattern, Blood pressure, Temperature, coma severity using GCS, pupillary size, extra ocular movements, corneal reflex, posture, and motor pattern. The main symptoms are ataxia or weakness, isolated cranial nerve palsy, mild alteration of tone, poor pulse volume, apnea, abnormal pupillary size and reaction, dizziness, Headache, abnormal extra ocular movements absent corneal reflex. Management of non-traumatic coma patients at hospital includes Monitoring of Intracranial pressure, Maintenance of an adequate cerebral perfusion pressure, Management of persistent intracranial hypertension and Monitoring of Electroencephalographic Seizure activity. Infections are the most common cause for the non-traumatic coma in several cases. The pattern of infectious caused are CNS infections > metabolic toxic exposure > encephalitis > Intoxication > hypoxic ischemic insults > Intracranial haemorrhages>miscellaneous>unknown cases. 40% of children are prone to Non traumatic coma per 10000 general population per year.

Erratum: Clinico-Etiological Profile and Predictors of Mortality of Nontraumatic Coma in Children of Upper Egypt: A Prospective Observational Study

Erratum: Clinico-Etiological Profile and Predictors of Mortality of Nontraumatic Coma in Children of Upper Egypt: A Prospective Observational Study

Clinico-Etiological Profile and Predictors of Mortality of Nontraumatic Coma in Children of Upper Egypt: A Prospective Observational Study.

Nontraumatic coma (NTC) is a considerable cause of morbidity and mortality in children. This prospective observational study aimed to determine the clinico-etiological profile of NTC in children and delineate clinical signs predicting mortality in Upper Egypt from June 2019 to May 2020. All children from 1 month of age to 16 years who were admitted with NTC were included in the study. All patients received full histories and physical examinations, including Glasgow Coma Scale (GCS). Routine laboratory investigations including complete blood count, electrolytes, blood sugar, serum creatinine, and liver function tests were performed for all patients. Specific investigations such as metabolic studies, lumbar punctures, brain computed tomography scans, and magnetic resonance imaging were done when indicated. The precise etiology was determined and clinical presentations for survivors and nonsurvivors were compared. Among the 137 cases of NTC identified, central nervous system (CNS) infections were the most common cause leading to 38 cases, followed by toxic causes in 37 cases, status epilepticus in 22 cases, and metabolic causes in 21 cases. Hypothermia, hypotension, abnormal respiratory patterns, muscle hypotonia, absent corneal reflex, presence of shock, and need for mechanical ventilation were significantly correlating with mortality. The estimated mortality rate was 18.2% and all cases with GCS < 5 died. Toxic causes were the most commonly identified etiology in patients who died. In conclusion, the authors identified several etiologies for NTC in Upper Egypt and their corresponding clinical signs at presentation. This information can be used to improve the clinical care provided to children with NTC.

Study on clinical profile and etiology of acute febrile encephalopathy in children aged between 2 months to 14 years attending to a tertiary care hospital, Eluru, Andhra Pradesh, India

Background: Acute febrile encephalopathy (AFE) is a common conditionleading to hospitalization of children in India. CNS infections are commonest cause of non-traumatic coma in children. Although AFE is one of the major causes of hospital admissions of children and adults in India, only a few studies have been done on it so far.So this study was conducted to study the clinical profile and etiology of AFE in children. Methods: This prospective study was carried out on 84 children between 2 months to 14 years, with fever duration of<14 days, GCS ≤12 at the time of admission and altered sensorium in the pediatric intensive care unit over a period of 12 months from August 2017 to August 2018. Clinical profile and etiology were evaluated. Results: Thepresent study, has identified viral encephalitis (38%) and pyogenic meningitis (34.5%) as the major causes of Acute febrile encephalopathy in the study population. Most common symptoms apart from fever and altered sensorium were vomiting (58.3%), convulsions (45.2%), headache (35.7%), jaundice (8.3%), and most common presenting clinical signs apart from fever and GCS< 12 were neck stiffness (52.4%), signs of raised ICT (47.6%), positive Kernig’s sign (39.2%), and motor tone abnormalities (34.5%). Conclusion: In this study, we observed that CNS infections are the most common cause of febrile encephalopathy in children. Early recognition of the clinical signs and immediate and appropriate treatment will combat the problem and improve the survival rate.

Etiological and evolutive aspects of toxic coma in children: a 7-year retrospective study

Toxic coma is a complication of acute poisoning and the most common cause of non-traumatic coma in children. We performed a retrospective study on a group of 154 children, aged 0-18 years old, admitted with toxic coma during 1.01.2011 and 31.12.2017. The study group included only the patients who received a Glasgow score < 8 at the initial evaluation. We excluded from the study all children with poisonings and other disorders of consciousness such as drowsiness or stupor (Glasgow score: 14-9). The study analyzed: the toxic products involved depending on age, sex, origin, and also the evolution after treatment administration. We noticed that toxic coma was prevalent in children over 12 years old (59%). Coma due to non-drugs poisonings was more frequent (68.8%) than drug-induced coma (31.2%). Only 20.7% of patients required orotracheal intubation. The evolution was favorable in most cases; only 3 deaths were registered (1.9%). Toxic etiology should be evoked in any coma of unknown cause that occurs suddenly in a previously healthy child.

Clinical profile and predictors of outcome in children with Non-traumatic Coma undergoing decompressive Craniectomy : A tertiary center experience

Background : Raised intracranial pressure (ICP) in non-traumatic coma (NTC) is common in children and requires urgent, protocol based management and multimodal monitoring. Initial tiers of raised ICP management are based on evidence based guidelines. However, treatment for refractory raised ICP is limited to medical measures like barbiturate coma, targeted therapeutic hypothermia or a neurosurgical procedure like decompressive craniectomy (DC). Evidence regarding the role of DC in refractory raised ICP due to NTC in children is lacking. Therefore, we planned to study the clinical profile and outcome of these patients undergoing DC. Methods : All patients aged 1 month to 12 years, admitted to a tertiary care pediatric ICU over a period of 5 years (2012 to 2017) and underwent DC for non-traumatic refractory raised ICP were retrospectively analysed. Clinical profile, course and neurological outcomes were studied. Primary outcome measures were survival to hospital discharge and neurological outcome after 3 months using Glasgow Outcome Scale (GOS). GOS of 1 & 2 were classified as good and 3 to 5 as poor. Statistical analysis was done using SPSS version 21 software. Descriptive data were summarized as mean ± SD or median (IQR). Predictors of good outcome were analysed using Chi Square test and multivariate logistic regression. Results : A total of 30 children with median age of 6.5 months (IQR 2, 50) were included. 26 (86.7%) were males. Common presenting symptoms were seizures (n=25; 83%), altered sensorium (n=19; 63%) and fever (n=12; 40%). Common clinical signs were pallor (n=20; 66.6%), asymmetric pupils (n = 15; 50%), bulging anterior fontanelle (n=12; 40%), focal deficits (n=6; 20%) and skin bleeds (n=4; 13%). Median (IQR) Glasgow Coma Score (GCS) at admission was 9 (6,11). Commonest etiology was intracranial bleed in 24 (80%) and infarct in 6 (20%). Location of bleed was parenchymal in 10 (33.3%), subdural 8 (26.7%), extradural 1 (3.3%) and multi-site in 5 (16.7%). All had a midline shift of >5mm on neuroimaging. Median (IQR) time to DC was 24 (24,72) hours of hospital admission. Twenty-six (86.7%) were ventilated for a median (IQR) duration of 96 (48, 144) hours and one patient required tracheostomy. Two patients died (6.6%) during hospital stay. Median (IQR) length of PICU and hospital stay was 5.5 (3, 10) and 17 (12, 27) days respectively. Twenty-one patients were examined at median (IQR) follow-up duration of 12 (5, 54) months. Six more patients died and one lost to follow-up. Good neurological outcome was seen in 15/29 (51.7%) patients. On univariate analysis, skin bleed (p-0.042), pupillary asymmetry (p-0.002) and focal deficit (p-0.011) at admission were significant predictors of poor outcome. On regression analysis, pupillary asymmetry at admission was predictive of poor neurological outcome [p-0.003]. Conclusion : Evidence on management of refractory raised ICP in NTC is still evolving. Timely DC can be considered as an effective treatment modality with good survival and neurological outcome.

Study of clinical profile, etiology and immediate outcome in Non-traumatic coma in children

Study of clinical profile, etiology and immediate outcome in Non-traumatic coma in children

Predictors of non-traumatic coma in a pediatric cohort from a South Indian tertiary care center: Results of a multivariate analysis

Objective: To study the etiology and clinical profile of non-traumatic coma in children at tertiary care center and to determine the predictors of outcome. Methods: One hundred and four consecutive children between 2 mo-12 yr were studied. The clinical signs at admission; vital signs, Glasgow coma scale, respiratory pattern, papillary reflex, extra-ocular movements, fundus picture and motor deficits were recorded. Etiology of coma was determined by clinical history, examination and relevant investigations. Their progress was monitored clinically, biochemically and with multi-system monitors. Outcome was recorded as survived or died. Results: Etiology of coma in 65% cases was intracranial infections; other causes were metabolic (20%). Sixty-seven percent recovered completely, 16% had residual neurodeficits, 16% died. Survival was better in children with intracranial infections (13%) as compared to metabolic coma (33%). On multivariate logistic regression, bradycardia, hypoten- sion, abnormal respiratory pattern (especially, ataxic type), duration of coma more than 48 h, Glasgow coma scale < 7 at ad- mission, unequal and non-reactive pupils, papilledema, abnormal extra-ocular movements, motor deficits, signs of meningitis correlated with mortality. Requirement of ventilatory support and abnormal computerized tomography findings correlated with mortality. Conclusions: Intracranial infections were the most common cause of non-traumatic coma in children; the most common cause of death being metabolic coma. Simple clinical signs and relevant investigations served as prognostic indicators of outcome.

Non traumatic coma in children: a prospective observational study

Background: Non Traumatic Coma (NTC) in children is an important pediatric emergency. It has been an enigma for clinicians for many years. To find the cause of coma and to determine the prognosis is a taxing question for the attending clinicians and the primary concern for relatives in every case. Objective: To study the etiology, clinical profile, and to determine the clinical signs predictive of outcome in non-traumatic coma in children aged between 6 months and 12 years. Methods: Sixty-one consecutive cases with details of demographic data, history and clinical examination at admission and after 48 hours were recorded in a predesigned proforma. The clinical variables recorded were heart rate, respiratory rate and pattern, blood pressure, temperature, coma severity (using modified Glasgow Coma Scale), pupillary size and response to light, extra ocular movements and fundus picture. Etiology was classified into infections, toxic-metabolic, hypoxic-ischemic, post-status epilepticus, intracranial bleeding and miscellaneous. The outcome was recorded as survived or died, and among those who survived as normal, mild, moderate, or severe disability. Results: Infection was the commonest cause of non-traumatic coma accounting for 25 (41%) cases. Toxic-metabolic 16 (26.2%), status-epilepticus in 10 (16.4%), 5 (8.2%) were caused by structural CNS lesions and in 5 (8.2%) cause could not be determined. In infectious causes, encephalitis was the largest subgroup contributing to 10 (16.4%) cases. Overall mortality was 33.9 % in our study. 40.9 % were normal or had mild disability and 23 % had moderate to severe disability when examined at discharge. The mortality was higher in cases of toxic-metabolic coma (43.8%) than in CNS infections (29.2%) or status-epileptics (10%). Factors that correlated significantly with mortality both at admission and after 48 hours were age ≤3, poor pulse volume, hypotension, abnormal respiratory pattern, abnormal pupils, absent corneal reflex, abnormal extra-ocular movements, lower modified GCS and papilledema. Conclusions: CNS infections are the commonest cause of non-traumatic coma; simple clinical signs are strong predictors of both morbidity and mortality.

Non-traumatic Coma in Children in South-East of Iran

scan or brain MRI (Magnetic Resonance Imaging), lumbar puncture, metabolic study, EEG (electroencephalogram), and so forth were carried out. Finally, the data were analyzed and the most common causes of loss of consciousness were determined. Results: Among the 123 children under investigation, 76 cases were male (61.8%) and 47 females (38.2%) with the mean age of 3.2 ± 0.64 years. The most common causes of loss of consciousness among children were as follows: toxic causes in 61 patients (49.6%), infectious causes in 30 patients (24.4%), metabolic causes in 11 patients (8.9%), structural brain abnormalities in 4 patients (3.3%) and seizure in 7 children (5.7%). Moreover, 10 patients (8.1%) had other causes of loss of consciousness. Conclusions: Toxic causes with an incidence of 49.6% were the most common cause of loss of consciousness among all age groups.

Non-Traumatic Coma and Altered Mental Status

Non traumatic coma in childhood is an important emergency. It can result from wide range of etiologies. CNS infections are the most common cause of non traumatic coma in children. However, multiple interrelated factors may be present in one patient. Management of a comatose child goes hand in hand with clinical evaluation. It is an emergency that requires simultaneous institution of immediate life support, identification of the cause and institution of definite therapy. The primary goal is to establish airway, breathing and circulation and to identify and treat raised intracranial pressure and seizures.

Non-traumatic childhood coma in Ebonyi State University Teaching Hospital, Abakaliki, South Eastern Nigeria

Coma is a medical emergency, and optimal management, especially in a resource-poor setting, would depend on the knowledge of its etiology and predictors of outcome. This communication reviews the etiology and outcome of non-traumatic childhood coma in Ebonyi State University Teaching Hospital (EBSUTH), Abakaliki. To determine the incidence, etiology and outcome of non-traumatic coma in children seen at the EBSUTH, Abakaliki. This is a retrospective analysis of records of all children admitted to the children emergency ward of EBSUTH in coma of a non-traumatic origin between 1 st of January and 31 st of December, 2007. Forty children presented with coma out of 673 children admitted during the study period, giving an incidence rate of 5.9%. The majority of the children (62.5%) were aged between 1 and 5 years of age, and 79.5% of them were deeply comatose on admission. Most of the cases (85%) of non-traumatic coma were due to infective causes, mainly cerebral malaria (47.5%), pyogenic meningitis (17.5%) and septicemia (10%). Twenty-four (60%) children recovered while 13 (32.5%) died. Infections were the predominant causes of non-traumatic coma in EBSUTH. In view of the high mortality among this group of patients, efforts at the control of malaria and other infections would significantly reduce the incidence of non-traumatic coma in this study site.

Predictive value of electroencephalography and computed tomography in childhood non-traumatic coma

To study value of electroencephalogram (EEG) and computed tomography (CT Scan) in predicting outcome of non-traumatic coma in children. 100 consecutive children, between 2 months to 12 years, with non-traumatic coma, (Glasgow Coma Scale score < 8). Demographic and clinical data was recorded at admission. EEG and CT scan were done within 24 hours of admission. Etiologic diagnosis was assigned on basis of clinical data and relevant laboratory investigations. The outcome was recorded as survived and died. Among survivors it was graded as no disability, or mild, moderate, or severe disability. Odds ratio and/or relative risk (RR) with 95% confidence interval (C I) were calculated. EEG could be done in 60 patients (43 survived; 7 were normal, 8 had mild, 17 moderate and 11 severe disability) CT scan in 93 patients (60 survived; 11 were normal, 14 had mild, 21 moderate and 14 severe disability). A normal/borderline EEG was associated with good outcome (P = 0.001); 11 of 12 survived and of survivors 55% had no or mild disability. Electrocerebral silence on EEG was a predictor of death (OR = 44 -sub .95% Cl - 1.5-7372; P = 0.01). An abnormal EEG was associated with significant increase in risk of disability among survivors (RR = 2.6, 95% Cl = 1.2-5.4, P = 0.03). Among CT abnormalities intracranial bleed suggested increased risk of death (RR = 2.1; 95% Cl - 0.8-5.3; P = 0.058), while, hydrocephalus was associated with better survival (RR = 0.7; 95% CI - 0.5 to 0.96; P = 0.029). However, hydrocephalus when compared with other abnormal CT scan findings, was associated with higher risk of moderate and severe disability among survivors (P = 0.046) A normal CT scan and EEG, and some of the specific findings could be helpful in predicting outcome in children with non-traumatic coma. EEG and CT scan should be done at admission in all patients with non-traumatic coma if feasible.

Non traumatic coma

To study the etiology and clinical profile of non-traumatic coma in children and to determine the clinical signs predictive of outcome. 100 consecutive cases of non-traumatic coma between 2 months to 12 years. Clinical signs studied were temperature, pulse, heart rate, blood pressure, coma severity by Glasgow coma scale (GCS), respiratory pattern, pupillary and corneal reflex, extra ocular movements, motor patterns, seizure types and fundus picture. These were recoded at admission and after 48 hours of hospital stay. Etiology of coma was determined on basis of clinical history, examination and relevant laboratory investigations by the treating physician. The outcome was recorded as survived or died, and among those who survived as normal, mild, moderate, or severe disability. Chi-square test and logistic regression analysis were done to determine predictors of outcome. Etiology of coma in 60% cases was CNS infection (tubercular meningitis-19, encephalitis-18, bacterial meningitis-16, others-7); other causes were toxic-metabolic conditions (19%), status epilepticus (10%), intracranial bleed (7%), and miscellaneous (4%). 65 children survived, 11 were normal, 14 had mild disability, 21 had moderate disability and 14 were severely disabled and dependent. Survival was significantly better in patients with CNS infection (63%) as compared to those with toxic-metabolic causes (27%) and intracranial bleed (43%, P < 0.05). On bivariate analysis age < or = 3 years, poor pulse volume, abnormal respiratory pattern and apnoea, abnormal pupillary size and reaction, abnormal extra ocular movements, absent corneal reflex, abnormal motor muscle tone at admission or 48 hours correlated significantly with mortality. Survival was better with increasing GCS (Spearman rho = .32, P < 0.001). On logistic regression age < 3 years, poor pulse volume, absent extraocular movements and papilloedema at admission and 48 hours after admission were independent significant predictors of death. CNS infections were the most common cause of non-traumatic coma in childhood. Simple clinical signs were good predictors of outcome.

72 Significance of Fast and Slow Periodicities in ICP and EEG During the Natural History of Severe Non-Traumatic Coma in Children

72 Significance of Fast and Slow Periodicities in ICP and EEG During the Natural History of Severe Non-Traumatic Coma in Children

Cerebral Intraparenchymal Pressure Monitoring in Non-Traumatic Coma: Clinical Evaluation of a New Fibreoptic Device

Initial reporting and validation of the Camino miniaturised fibreoptic cerebral intraparenchymal pressure monitoring device has indicated that this tip transducing system (a) allows direct measurement of brain tissue pressure, (b) has a rapid response rate to intracranial changes and (c) correlates well with intraventricular pressure. However, there are no specific reports of this form of monitoring during non-traumatic coma in children, or any evaluation of change in clinical practice when compared with experience of other forms of invasive intracranial pressure monitoring. Over a 5-year-period (1985-1989) on the General Paediatric Intensive Care Unit, 74 children with presumed raised intracranial pressure complicating non-traumatic coma have had invasive intracranial pressure monitoring with a variety of devices. An intraventricular catheter was used in 16 patients, a subdural catheter in 6 patients, a subarachnoid screw in 35 patients and a fibreoptic intraparenchymal catheter in 17 patients. In 1985 to 1986 our preferred technique was the subarachnoid screw (33/49 patients monitored). Between 1987 and 1989 we have mainly used the Camino fibreoptic intraparenchymal monitoring system (17/25 patients monitored). In the whole series there were no cases of acute haemorrhage related to monitoring and only one patient developed infection and in this child an intraventricular catheter was used. The experience with the fibreoptic system has been favourable and the technique for insertion does not require additional expertise in comparison with standard subarachnoid screw pressure monitoring. Therefore in young children with raised intracranial pressure complicating non-traumatic coma, cerebral fibreoptic intraparenchymal pressure monitoring should be used in preference to standard subarachnoid screw pressure monitoring.(ABSTRACT TRUNCATED AT 250 WORDS)