States Of Impaired Consciousness Research Articles

Diagnostic criteria for prolonged and chronic disturbances of consciousness after aneurysmal subarachnoid hemorrhages

In recent years, prolonged states of impaired consciousness became widespread among patients with aneurysmal subarachnoid hemorrhage. Treatment and maintenance of vital functions in such patients represent a complex medical, economic and social problem. In this regard, searching for the causes of prolonged states of impaired consciousness and predicting the outcomes are important. To analyze available literature data on prevention and treatment of prolonged states of impaired consciousness after aneurysmal subarachnoid hemorrhage. We reviewed the PubMed database using the keywords «unresponsive wakefulness syndrome», «persistent vegetative state2, «minimal consciousness state» and «outcome of subarachnoid hemorrhage». Only 4 reports devoted to the causes and treatment outcomes in patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage were found. At the same time, patients with aneurysmal subarachnoid hemorrhage comprise up to 11% among all cases of prolonged states of impaired consciousness. Examination, management and treatment of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage are carried out according to general principles without taking into account specific etiological and pathogenetic factors. Increased number of patients with prolonged impairment of consciousness after aneurysmal subarachnoid hemorrhage necessitates analysis of etiopathogenesis and outcomes of these disorders based on modern clinical, instrumental and laboratory assessment of the brain.

The lack of temporal brain dynamics asymmetry as a signature of impaired consciousness states.

Life is a constant battle against equilibrium. From the cellular level to the macroscopic scale, living organisms as dissipative systems require the violation of their detailed balance, i.e. metabolic enzymatic reactions, in order to survive. We present a framework based on temporal asymmetry as a measure of non-equilibrium. By means of statistical physics, it was discovered that temporal asymmetries establish an arrow of time useful for assessing the reversibility in human brain time series. Previous studies in human and non-human primates have shown that decreased consciousness states such as sleep and anaesthesia result in brain dynamics closer to the equilibrium. Furthermore, there is growing interest in the analysis of brain symmetry based on neuroimaging recordings and since it is a non-invasive technique, it can be extended to different brain imaging modalities and applied at different temporo-spatial scales. In the present study, we provide a detailed description of our methodological approach, paying special attention to the theories that motivated this work. We test, for the first time, the reversibility analysis in human functional magnetic resonance imaging data in patients suffering from disorder of consciousness. We verify that the tendency of a decrease in the asymmetry of the brain signal together with the decrease in non-stationarity are key characteristics of impaired consciousness states. We expect that this work will open the way for assessing biomarkers for patients' improvement and classification, as well as motivating further research on the mechanistic understanding underlying states of impaired consciousness.

Do Cognitively Impaired Elderly Patients with Cancer Respond Differently on Self-reported Symptom Scores? A 5-Year Retrospective Analysis.

Objectives:An increasing number of elderly subjects with cancer were admitted to the palliative care unit and they have suffered both distressing symptoms and cognitive impairment. We aim to identify the prevalence of cognitive impairment among elderly cancer patients receiving in-patient palliative care and to examine any difference between patients with cognitive impairment on self-reported symptoms.Materials and Methods:Subjects’ age ≥65 admitted to a palliative care unit from 01 September 2015 to 31 August 2020 was included in the study. Exclusion criteria were those with an impaired conscious state, severe cognitive impairment, or language problems that were non-communicable. Variables collected included baseline demographics, cancer diagnosis, cancer stage, mobility state using the modified Barthel index (mBI), and performance status as measured by the palliative performance scale. Cognitive impairment was defined by abbreviated mental test ≤6. Self-reported symptoms scales were measured by the Chinese version of MD Anderson Symptom Inventory and EORTC QLQ C-30 (European Organisation for Research and Treatment of Cancer, Quality of Life Core Questionnaire 30).Results:Nine hundred and ninety-one subjects with 1174 admissions were retrieved. Eight hundred and seventy-three admission episodes were included in this study. Three hundred and eight (35%) have cognitive impairment. Cognitively impaired subjects were older, showed worse physical function and performance status, and more often residing in old age homes. Independent predictors of cognitive impairment were age (OR 1.09), mBI (OR 0.96), chair/bed bound state (OR 1.79), and presence of brain metastasis (OR 2.63). They reported lower scores in pain (P < 0.001), distress (P < 0.001), sleep disturbance (P < 0.001) and nausea and vomiting (P = 0.012) in the self-reported symptoms scale.Conclusion:Elderly cancer patients with cognitive impairment were older with poorer performance status. They have reported a lower level of pain, distress, and sleep disturbance. Clinicians should be alerted to this phenomenon to tackle the unmet concomitant symptoms.

Nonconvulsive Status Epilepticus: Current Status and Future Perspectives

AbstractIntroduction Nonconvulsive status epilepticus is defined as a state of impaired consciousness with subtle motor manifestations and ongoing seizure activity in the electroencephalogram (EEG) for at least 30 minutes.Objectives and Methods This study of nonconvulsive status epilepticus and its outcomes was a retrospective analysis of the continuous bedside EEG recordings of 100 patients over 2 years (Aug 2017–July 2019) at the Neurophysiology Department in Sir Ganga Ram Hospital, New Delhi. There were two groups of patients in the study comprising of adults (72) and children (28). A comparison between the two groups was made based on the clinical presentation, etiology, EEG, MRI findings, treatment, and the consequences.Results and Conclusions In adults, nonconvulsive status had a high mortality rate, while in children, the associated comorbidities dominated and contributed to residual neurological sequelae. Early diagnosis and treatment at any age is essential to prevent cognitive decline and psychomotor retardation. Presently, bedside and ambulatory EEG recordings are used to capture the dynamic and rhythmic features of the ictal EEG. Continuous EEG monitoring enables bedside assessment of the effectiveness of treatment.

83. DAMAGING RARE CODING VARIANTS IDENTIFIED BY EXOME SEQUENCING ARE ASSOCIATED WITH REDUCED COGNITIVE FUNCTION IN SCHIZOPHRENIA

Disorders of consciousness (DOC) following severe structural brain injuries globally affect the conscious state and the expression of goal-directed behaviors. In some subjects, neuromodulation with medications or electrical stimulation can markedly improve the impaired conscious state present in DOC. We briefly review recent studies and provide an organizing framework for considering the apparently widely disparate collection of medications and approaches that may modulate the conscious state in subjects with DOC. We focus on neuromodulation of the anterior forebrain mesocircuit in DOC and briefly compare mechanisms supporting recovery from structural brain injuries to those underlying facilitated emergence from unconsciousness produced by anesthesia. We derive some general principles for approaching the problem of restoration of consciousness after severe structural brain injuries, and suggest directions for future research.

Rehabilitating the neurological patient in the ICU: what is important?

To describe recent literature evaluating the effectiveness of early rehabilitation in neurocritical care patients. There is a drive for early rehabilitation within the ICU; however, there are unique considerations for the neurocritically ill patient that include hemiplegia, cognitive impairments and impaired conscious state that can complicate rehabilitation. Additionally, neurological complications, such as hemorrhage expansion and cerebral edema can lead to the risk of further neurological damage. It is, therefore, important to consider the effect of exercise and position changes on cerebral hemodynamics in patients with impaired cerebral autoregulation. There is a paucity of evidence to provide recommendations on timing of early rehabilitation postneurological insult. There are also mixed findings on the effectiveness of early mobilization with one large, multicenter RCT demonstrating the potential harm of early and intensive mobilization in stroke patients. Conversely, observational trials have found early rehabilitation to be well tolerated and feasible, reduce hospital length of stay and improve functional outcomes in neurological patients admitted to ICU. Further research is warranted to determine the benefits and harm of early rehabilitation in neurological patients. As current evidence is limited, and given recent findings in stroke studies, careful consideration should be taken when prescribing exercises in neurocritically ill patients.

AN OBSTACLE AROUND THE CORNER

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Post obstructive pneumonia (POP) is found in 2-5% of patients with community acquired pneumonia (CAP), characterized by infection distal to a mechanical obstruction of the bronchus. Post obstructive pneumonia is in the differential diagnosis in patients with recurrent infections in the same lung segment(s). Bronchoscopic intervention is usually diagnostic and may also be therapeutic in certain cases. We present a case of post obstructive pneumonia which was later found to be secondary to foreign body aspiration. CASE PRESENTATION: A 60-year old woman was admitted to the hospital for recurrent right lower lobe pneumonia. She endorsed cough with dark green sputum, shortness of breath, drenching night sweats and a 30lb unintentional weight loss in the preceding 6 months. She had a history of recurrent pneumonias for the past eighteen months, with chest imaging that revealed similar right lower lobe infiltration. On physical examination she was afebrile with unremarkable vital signs. Auscultation revealed right lower lobe crackles. Procalcitonin was 0.06 ng/mL and WBC was 10.32. A CT chest demonstrated a right lower lobe infiltrate and possible endobronchial lesion. (Figure 1) Due to concern for endobronchial mass, bronchoscopy was performed which revealed a mobile obstructing mass in the right lower lobe that was retrieved with forceps. There was moderate amount of purulent secretion distal to the obstruction. (Figure 2) Pathology revealed “probable vegetable matter” (Figure 3) and bronchoalveolar lavage (BAL) cultures grew Streptococcus Sanguinis. She was discharged with amoxicillin/clavulanic acid. DISCUSSION: In patients with recurrent pneumonia in the same lung segment, the differential is broad and includes post obstructive pneumonia (POP), ”non-resolving pneumonia” (due to infectious and non-infectious causes) and aspiration. In patients with POP, the most common etiology of obstruction is malignancy, including malignant and benign tracheobronchial tumors. [1,3] The microbiology is diverse and spans gram positive, gram negative and anerobic bacteria thus broad coverage is often initially indicated. [2] Features that distinguish POP from CAP include a lower likelihood of leukocytosis, bandemia, elevated procalcitonin, or fever. With POP there is often >5% weight loss and have increased duration of symptoms. [1] Foreign body aspiration in adults occurs with swallowing disorders of varying etiologies and in states of impaired consciousness. Food causes a more prominent inflammatory reaction (acute and chronic bronchus inflammation in our patient) compared with inorganic objects. CONCLUSIONS: In a patient with recurrent pneumonia in the same lung segment with constitutional symptoms consider post obstructive pneumonia. Workup and treatment includes CT imaging, bronchoscopy and antibiotics. Reference #1: Abers, M.S., et al., Postobstructive Pneumonia: An Underdescribed Syndrome. Clin Infect Dis, 2016. 62(8): p. 957-61. Reference #2: Rolston, K.V.I. and L. Nesher, Post-Obstructive Pneumonia in Patients with Cancer: A Review. Infect Dis Ther, 2018. 7(1): p. 29-38. Reference #3: Stevic R, Milenkovic B. Tracheobronchial tumors. J Thorac Dis. 2016;8(11):3401–3413. DISCLOSURES: No relevant relationships by Giuliana Cerro, source=Web Response No relevant relationships by George Chaux, source=Web Response No relevant relationships by Michael Lewis, source=Web Response No relevant relationships by Jason Wong, source=Web Response

Clinical and epidemiological analysis of severe traumatic brain injury: the role of nutritional support to the injured with a prolonged state of impaired consciousness

Relevance. Patients with prolonged impaired consciousness due to traumatic brain injury are the most difficult category of patients in inpatient medical rehabilitation units. Despite the experience gained in managing this complex category of patients, the problem of nutrition status and trophological insufficiency, as well as practical issues regarding the organization of optimal nutrition at this stage of medical rehabilitation remain unresolved.Intention. To study the role of nutritional support for patients with long-term impaired consciousness on the basis of a clinical and epidemiological analysis of severe traumatic brain injury.Methodology.The data of an epidemiological analysis of traumatic brain injuries and features of ongoing nutritional support in patients with long-term impaired consciousness are presented, based on a study of domestic and foreign publications from 2005 to 2019.Results and Discussion. Timely and adequate nutritional support optimizes the structural-functional and metabolic systems of the body, adaptive reserves interfere with rapidly progressive depletion and chronic catabolic processes, contribute to positive changes in the functional state of the brain, reduce infectious complications, and increase the effectiveness of rehabilitation measures and the rate of recovery of consciousness.Conclusion. The analysis revealed the ambiguity of the interpreted data on clinical recommendations and approaches to the use of nutritional support in patients with long-term impaired consciousness due to traumatic brain injury. Considering the fact that in most cases such patients need continuous long-term comprehensive rehabilitation measures, accompanied by significant energy costs of the body, an essential component of the rehabilitation process, in our opinion, is the inclusion of adequate nutritional support that prevents fast-progressing exhaustion and chronic catabolic processes. In this regard, such an urgent task is to optimize the algorithms of nutritional support in patients with long-term impaired consciousness after a traumatic brain injury, the solution of which will improve the functional state of the brain and, therefore, the rehabilitation prognosis and quality of their life.

The state of erection in a patient with craniopharyngioma, panhypopituitarism and diencephalic obesity

The article presents a clinical case from the practice of a patient with craniopharyngioma. The man of reproductive age with diencephalic obesity (BMI 35 kg/m2), recurrent craniopharyngioma, a long history of endocrine disorders (panhypopituitarism, including secondary hypogonadism, with the corresponding sexual function disorders and the lack of sexual activity), with visual disorders and psychiatric symptoms in the early postoperative period after shunting surgery and reducing the volume of the craniopharyngioma cyst, erection conditions arose against the background of episodes of disorders of consciousness within the framework of sleep dissociation.&#x0D; After the operation (installation of the Ommaya system), the patient had a state of spontaneous erection lasting up to 30 minutes against the background of dream-oneiric states of impaired consciousness with erotic experiences. These states were observed for 3 nights, the patient remembered the experiences and events that occurred to him in a dream, and could tell about them to others on the next morning. The identity of the patient remained intact, he was active in the department, ordered in behavior; memory for current events and new information was intact. These disorders in the patient did not require specialized treatment, regressed independently on the 6th day of the postoperative period.

P06-T The usefulness of monitoring EEG activity in unconscious patients treated in the neurological ICU

Background Patients in critical condition, especially being in a state of impaired consciousness, treated in the neurological intensive medical care units require a detailed assessment of brain activity. Long term monitoring of EEG activity allows the detection of neuronal dysfunction as a consequence of structural or metabolic damage of CNS, even in the absence of abnormalities in the clinical examination. Material and methods We present the case of patients treated in the Department of Neurology, Medical Universities in Lublin, whose continuous monitoring of bioelectrical activity of the brain led to improvements in diagnosis and therapy. Conclusions The technique of continuous monitoring of EEG activity can significantly improve the clinical assessment and the ability to care for unconscious patients.

Electromagnetic Brain Stimulation in Patients With Disorders of Consciousness.

Severe brain injury is a common cause of coma. In some cases, despite vigilance improvement, disorders of consciousness (DoC) persist. Several states of impaired consciousness have been defined, according to whether the patient exhibits only reflexive behaviors as in the vegetative state/unresponsive wakefulness syndrome (VS/UWS) or purposeful behaviors distinct from reflexes as in the minimally conscious state (MCS). Recently, this clinical distinction has been enriched by electrophysiological and neuroimaging data resulting from a better understanding of the physiopathology of DoC. However, therapeutic options, especially pharmacological ones, remain very limited. In this context, electroceuticals, a new category of therapeutic agents which act by targeting the neural circuits with electromagnetic stimulations, started to develop in the field of DoC. We performed a systematic review of the studies evaluating therapeutics relying on the direct or indirect electro-magnetic stimulation of the brain in DoC patients. Current evidence seems to support the efficacy of deep brain stimulation (DBS) and non-invasive brain stimulation (NIBS) on consciousness in some of these patients. However, while the latter is non-invasive and well tolerated, the former is associated with potential major side effects. We propose that all chronic DoC patients should be given the possibility to benefit from NIBS, and that transcranial direct current stimulation (tDCS) should be preferred over repetitive transcranial magnetic stimulation (rTMS), based on the literature and its simple use. Surgical techniques less invasive than DBS, such as vagus nerve stimulation (VNS) might represent a good compromise between efficacy and invasiveness but still need to be further investigated.

Neuropsychological Characteristics of the Confusional State Following Traumatic Brain Injury.

Individuals with moderate-severe traumatic brain injury (TBI) experience a transitory state of impaired consciousness and confusion often called posttraumatic confusional state (PTCS). This study examined the neuropsychological profile of PTCS. Neuropsychometric profiles of 349 individuals in the TBI Model Systems National Database were examined 4 weeks post-TBI (±2 weeks). The PTCS group was subdivided into Low (n=46) and High Performing PTCS (n=45) via median split on an orientation/amnesia measure, and compared to participants who had emerged from PTCS (n=258). Neuropsychological patterns were examined using multivariate analyses of variance and mixed model analyses of covariance. All groups were globally impaired, but severity differed across groups (F(40,506)=3.44; p&lt;.001; ŋp 2 =.206). Rate of forgetting (memory consolidation) was impaired in all groups, but failed to differentiate them (F(4,684)=0.46; p=.762). In contrast, executive memory control was significantly more impaired in PTCS groups than the emerged group: Intrusion errors: F(2,343)=8.78; p&lt;.001; ŋ p 2=.049; False positive recognition errors: F(2,343)=3.70; p&lt;.05; ŋp 2=.021. However, non-memory executive control and other executive memory processes did not differentiate those in versus emerged from PTCS. Executive memory control deficits in the context of globally impaired cognition characterize PTCS. This pattern differentiates individuals in and emerged from PTCS during the acute recovery period following TBI. (JINS, 2019, 25, 302-313).

Childhood Acute Bacterial Meningitis: Clinical Spectrum, Bacteriological Profile and Outcome.

To determine the disease pattern, etiological agents and outcome of childhood acute bacterial meningitis. Adescriptive study. Department of Paediatric Medicine, The Children's Hospital, Lahore, from January to December 2012. Atotal of 199 children between the ages of 1 month and 5 years, admitted with the diagnosis of meningitis on the basis of clinical findings and positive cerebrospinal fluid (CSF), were included. In all patients, complete blood count (CBC), CSF culture sensitivity, and blood culture sensitivity were performed. Data was analysed using SPSS version 20. Out of 199 children, 127 (63.8%) were males with M:F ratio of 1.7:1. Mean age was 11.33 ±12 months. Maximum numbers of children were < 1 year of age, 136 (68.3%). Only 90 (45.2%) children were fully vaccinated according to Expanded Program of Immunisation (EPI) schedule. Presentations with refusal to take feed (p=0.008) and with impaired conscious state were independent predictors of death (p=0.002). Complications were noted in 34 (17%) and were significantly associated with severe malnutrition (p=0.006) and altered conscious level at presentation (p < 0.001). The common pathogens identified on CSF culture were coagulase negative staphylococci (CoNS) in 11 (5.5%) and streptococcus pneumoniaein 5 (2.5%). Overall mortality was 10.1%. The commonest pathogen isolated from children who died was streptococcus pneumoniae(p=0.039). Acute bacterial meningitis mostly affected children under the age of 1 year. CSF culture revealed both Grampositive and Gram-negative bacteria. The most common pathogen in children who died was streptococcus pneumoniae.

Pediatric Absence Status Epilepticus: Prolonged Altered Mental Status in an 8-Year-Old Boy.

Absence status epilepticus is characterized by a prolonged state of impaired consciousness or altered sensorium with generalized electroencephalographic abnormalities. It is most commonly diagnosed in patients with known idiopathic generalized epilepsy; however, it may also be the first presentation of epilepsy. Due to the subtle and variable manifestations of the condition, absence status epilepticus may be underrecognized, particularly in children. We present the case of an 8-year-old boy who experienced two episodes of prolonged altered mental status, subsequently determined to be absence status epilepticus with idiopathic generalized epilepsy with phantom absences. We discuss the classification, pathophysiology, clinical presentation, and electroencephalographic findings of pediatric absence status epilepticus and provide a practical overview for management.

Various States of Impaired Consciousness Observed from EEG

Various States of Impaired Consciousness Observed from EEG

Anti-N-methyl-d-aspartate receptor encephalitis associated with ovarian teratoma: clinical presentation, diagnosis, treatment, and surgical management

Anti-N-methyl-d-aspartate (NMDA) receptor encephalitis is a newly recognized autoimmune disorder with prominent neuropsychiatric symptoms, usually part of a paraneoplastic syndrome. We present two cases of patients with anti-NMDA receptor encephalitis related to ovarian teratoma. Our two patients developed neuropsychiatric symptoms and later evolved into a state of impaired consciousness. The physical examinations and investigations, including routine laboratory testing, a basic metabolic panel, MRI of the brain, and the cerebrospinal fluid (CSF) analysis were non-specific. CT scan and MRI of the pelvis revealed a calcified tumor that was suspected to be an ovarian teratoma in both patients. Each patient underwent salpingo-oophorectomy, and histopathological diagnosis of the patient of case 1 was mature cystic teratoma and that of case 2 was immature teratoma. Finally, the result of the anti-NMDA receptor antibody assay demonstrated high antibody titers in CSF, leading to definite diagnosis of anti-NMDA receptor encephalitis triggered by ovarian teratoma in both cases. Given that anti-NMDA receptor encephalitis often results in severe symptoms regardless of the tumor size of the ovarian teratoma, accurate diagnosis of the teratoma followed by prompt surgical resection of the tumor is crucial for the treatment of anti-NMDA receptor encephalitis. The clinical presentation, diagnosis, treatment, surgical management, and prognosis, as well as a review of this disorder, were discussed in this case conference.

Can they suffer? The ethical priority of quality of life research in disorders of consciousness

There is ongoing ethical and legal debate about withdrawing life support for patients with disorders of consciousness (DOCs). Frequently fueling the debate are implicit assumptions about the value of life in a state of impaired consciousness, and persistent uncertainty about the quality of life (QoL) of these persons. Ye t there are no validated methods for assessing QoL in this population, and a significant obstacle to doing so is their inability to communicate. Recent neuroscientific discoveries might circumvent that problem and help shed light on QoL in DOCs. There is an ethical imperative to prioritize QoL research in this patient population, to provide evidence to inform treatment, research, and end of life decisions. A minimalist and pragmatic model of QoL is proposed, targeting positive and negative affects as domains for which there is potential to reach across the communication gap, and restore to these voiceless persons some measure of control. Key terms: Ve getative state, disorders of consciousness, minimally conscious state, quality of life, functional neuroimaging

Three Core Domains of Delirium Validated Using Exploratory and Confirmatory Factor Analyses

To confirm the existence of the proposed three-core symptom domains in delirium by analyzing a dataset of nondemented adults using selected core symptoms as measured by the Delirium Rating Scale-Revised-98 (DRS-R98) scale. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) of proposed delirium core symptoms were conducted in a pooled international dataset of 592 delirious and nondelirious patients using DSM-IV criteria from 14 studies with comparable methodologies. Using DRS-R98 categorization, 445 had either subsyndromal or full delirium and comprised the delirium group. The dataset was divided into three independent random subsamples to perform a stepwise analysis. First we performed EFA in 100 cases to delineate latent factor loadings of DRS-R98 items selected to represent the three-core domains (circadian, higher level thinking, and cognitive). These items were then assessed using CFA-modeling (n = 246) followed by a CFA-validation (n = 246). Reliability and goodness of fit of these two CFA were assessed statistically. DRS-R98 items representing the proposed delirium core symptoms loaded onto one factor in the EFA, supporting their core nature. The two CFA confirmed the nature of this core factor as comprising three core domains where DRS-R98 items each loaded with high values (>0.7) onto their corresponding core domain (circadian, higher level thinking, and cognitive) with good fit and reliability. Attention was DRS-R98 item with the highest loading in CFA, followed by thought process, and then by sleep-wake cycle and motor behavior. Our EFA and CFA confirm and validate the proposed three-core domains of delirium, where symptoms were highly related to the domain that they were hypothesized to represent. These domains are consistent with delirium being a state of impaired consciousness, and should be considered necessary to assess whether in clinical or research settings.

Coma blisters after poisoning caused by central nervous system depressants: case report including histopathological findings

Blister formation and eccrine sweat gland necrosis is a cutaneous manifestation associated with states of impaired consciousness, most frequently reported after overdoses of central nervous system depressants, particularly phenobarbital. The case of a 45-year-old woman who developed "coma blisters" at six distinct anatomic sites after confirmed (laboratory) phenobarbital poisoning, associated with other central nervous system depressants (clonazepam, promethazine, oxcarbazepine and quetiapine), is presented. A biopsy from the left thumb blister taken on day 4 revealed focal necrosis of the epidermis and necrosis of sweat gland epithelial cells; direct immunofluorescence was strongly positive for IgG in superficial blood vessel walls but negative for IgM, IgA, C3 and C1q. The patient was discharged on day 21 with no sequelae.

Approach to the Child with Coma

Coma and other states of impaired consciousness represent a medical emergency. The potential causes are numerous, and the critical window for diagnosis and effective intervention is often short. The common causes of non-traumatic coma include central nervous system infections, metabolic encephalopathy (hepatic, uremic, diabetic ketoacidosis etc.), intracranial bleed, stroke and status epilepticus. The basic principles of management include 1) Rapid assessment and stabilization, 2) Focussed clinical evaluation to assess depth of coma, localization of lesion in the central nervous system and possible clues to etiology, and 3) Treatment including general and specific measures. Commonly associated problems such as raised intracranial pressure and seizures must be recognized and managed to prevent secondary neurologic injury.