Convulsion And Coma

Convulsion: Uncontrollable shaking or a violent shaking of the body or limbs caused by
uncontrollable muscle contractions which can be a symptom of brain disorders and other
conditions.
Differential Diagnosis
• Epilepsy/status epilepticus
• Viral encephalitis
• Febrile seizures (more common in children)
• Migraine
• Malaria
• Hypoglycaemia
• Electrolyte imbalance
• Cerebral hemorrhage
• Space occupying lesions (e.g. toxoplasmosis, neurocysticercosis)
Investigations and Treatment of Convulsions
At Primary Health Care Facilities (Dispensary and Health Centre)
• Blood sugar (preferably using a glucometer)
• Blood slide for malaria parasites
At Higher Centres
• Lumbar puncture & cerebral spinal fluid analysis
• Serum electrolytes analysis
• Liver and renal function tests
Others Investigations
• CT scan of the brain
Treatments
Convulsing patient should be referred to hospital, at primary health care facility level do prereferral
treatment as follows
• Remove the patient from danger or remove the danger to the patient
• Maintain airway, breathing, and circulation
• Monitor vital signs
• Remove tight clothes
• Don’t put anything in the mouth
• Don’t try to stop the seizures physically
• Give diazepam 10mg IV initially then repeat after 15 minutes if seizures recur
(max of 30 mg)
• Initiate I/V line and refer the patient to a higher center for management of the cause
Clinical Feature, Differential Diagnosis, and Investigations of Coma
Clinical Feature
• Unconscious for more than half an hour
Differential Diagnosis
• Meningitis
• Encephalitis
• Cerebral abscess
• Subarachnoid hemorrhage
• Brain-stem infarction/hemorrhage
• Drug overdose
• Diabetes mellitus
Hypoglycaemia
Ketoacidosis
Hyperosmolar coma
Diagnosis
• Perform Glasgow Coma Score
Glasgow Coma Scale
Assessment of Level of Consciousness
• Asses the level of consciousness by using Glasgow coma scale
Glasgow Coma Scale (GCS)
Eye Opening
• Spontaneous 4
• To voice 3
• To pain 2
• None 1
Verbal Response
• Oriented 5
• Confused 4
• Inappropriate words 3
• Incomprehensible sounds 2
• None 1
Motor Response
• Obey command 6
• Localises pain 5
• Withdraws (pain) 4
• Flexion (pain) 3
• Extension (pain) 2
• None 1
Total
• Total Score 3-15
• Mildly severe 15-13
• Moderately severe 12-8
• Severe 7-3
• This predicts the severity and expectation of the patients and must be done frequently
• It guides the clinician whether the patient’s condition improves or deteriorates overtime
Investigations
• Depends on the most likely cause of coma
• Collateral history and physical examination
• Findings may suggest type of investigations to be done
Blood sugar
Perform lumbar puncture to obtain cerebral spinal fluid for analysis
Serum electrolytes analysis
Liver function tests
Blood slide for malaria parasites
• Others
CT scan of the brain (when appropriate)
Treatment and Prognosis of Coma
• Refer the patient immediately after initial resuscitation using ABCs protocol.
• The immediate goal in acute coma is the prevention of further nervous system damage.
• Hypotension, hypoglycemia, hypercalcemia, hypoxia, hypercapnia, and hyperthermia
should be corrected rapidly and attentively.
• An oropharyngeal airway is adequate to keep the pharynx open in drowsy patients who
are breathing normally.
• Tracheal intubation is indicated if there is apnea or upper airway obstruction,
hypoventilation, emesis or if the patient is liable to aspirate because of coma.
• Intravenous access is established and naloxone and dextrose are administered if narcotic
overdose or hypoglycemia is even remote possibility and thiamine is given with glucose
in order to avoid eliciting Wernicke disease in malnourished patients.
• In cases of suspected basilar thrombosis with brainstem ischemia, intravenous heparin or
a thrombolytic agent has often utilized keeping in mind that cerebella and pontine
hemorrhages resemble basilar artery occlusion (this should be done in a hospital).
• In situation of coma hypotonic or hypertonic solutions should NOT be given (it is best to
give isotonic solutions such as normal saline or ringers).
• Cervical spine injuries must not be overlooked particularly prior to attempting intubation
or the evaluation of oculocephalic responses.
• Headache accompanied by fever and meningismus indicates an urgent need for
examination of the CSF to diagnose meningitis.
• If the lumbar puncture in a case of suspected meningitis is delayed for any reason
antibiotics such as a third generation cephalosporin should be administered as soon as
possible (then efforts to do LP should be done without delay).
• Hyperosmolar therapy with mannitol or an equivalent agent is the mainstay of
intracranial pressure reduction.
Prognosis
• The prediction of the outcome of coma must be considered in reference to long-term care
and medical resources.
• Metabolic comas have a far better prognosis than traumatic comas.
• All schemes for prognosis in adults should be taken as approximate indicators and
medical judgments must be tempered by factors such as age, underlying systemic disease
and general medical condition.                                                                         
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