Pediatric emergency medicine trisk 0449 0449

The neurologic examination of the comatose patient should include standard tests
of eye opening, responsiveness to verbal and tactile stimuli, and deep tendon
reflexes as well as the more specialized examinations described in this section.
Any focal (unilateral) abnormal finding is always significant because it may
indicate a structural CNS lesion. Abnormal findings on neurologic examination
reflect the underlying pathologic condition causing coma and may allow
localization of a lesion within the brain.
Patients with ALOC benefit from quantification of their impairment using
standard measurements, allowing evaluation and documentation of patients’
changing neurologic status over time. The effect of medical interventions may
then be more easily assessed. The use of accepted scoring systems also facilitates
communication with consultants such as neurologists and neurosurgeons. In
addition, many outcome measures of neurologically injured patients rely on
scales used to assess neurologic function. The most widely used measurement of
consciousness is the Glasgow Coma Scale (GCS) shown in Table 17.1 . Patients
are graded on three areas of neurologic function: Eye opening, motor response,
and verbal responsiveness. A GCS score of 3 is the minimum score possible and
represents complete unresponsiveness; a GCS score of 15 indicates a fully alert
patient.
Pupillary responses provide the most direct window to the brain of a comatose
patient. A unilaterally enlarging pupil (greater than 5 mm) that becomes
progressively less reactive to light indicates either progressive displacement of
the midbrain or medial temporal lobe, or downward displacement of the upper
brainstem. Bilateral enlarged and unreactive (“blown”) pupils indicate profound
CNS dysfunction and are most commonly seen with posttraumatic increases in
ICP. Nontraumatic conditions affecting the brain diffusely usually spare pupillary
responses. Exceptions include maximal constriction of pinpoint pupils caused by
opiate intoxication and minimal constriction of widely dilated pupils caused by
intoxication with anticholinergic agents.
Other ocular signs noted in patients with depressed consciousness are the
roving side-to-side conjugate eye movements seen in lighter stages of metabolic

coma. Persistent conjugate deviation of the eyes to one side may be caused by
focal seizure activity, its resultant postictal state, or focal lesions within the brain.
Ongoing seizure activity is usually apparent because of the jerking ocular
movements present but nonconvulsive status may present with coma only. Most
structural brainstem lesions abolish conjugate eye movements, but it is rare for a
metabolic disorder to do so. Deepening ALOC may also be measured by the
reduction and loss of spontaneous blinking, then loss of blinking caused by