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Sensorium in Children

Dr. Gurdev Chowdhary, et. al

Page 3

Topics

Cyanosis

  • Cyanotic congenital heart disease
  • Brain abscess, Infarct, Cyanotic spell
  • Hypoxia
  • Shock

Edema

  • Chronic renal failure
  • Chronic liver disease
  • Congestive heart failure

Nutritional status: Patient may be poorly nourished in:

  • Insulin dependent diabetes mellitus
  • Inborn errors of metabolism
  • Renal failure

Breath odour: Certain distinct odours may be discernable in the following conditions :

  • Diabetic ketoacidosis: fruity smell
  • Hepatc encephalopathy : mousy odour
  • Uremic encephalopathy : mousy odour
  • Aluminum phosphide poisoning: Garlic odour
  • Kerosene poisoning: Smell of hydrocarbon

Heart rate

  • Tachycardia: along with decreased blood pressure may suggest hypovolemic shock.
  • Bradycardia: increased intracranial tension.

Pattern of breathing

a) Cheyne – Stokes breathing (also called periodic breathing ): Term used for a pattern of breathing in which there is a phase of gradual deepening of respiration followed by a phase of slowly decreasing respiratory rate. Respiration gradually becomes quieter and may cease for a few seconds. The cycle is then repeated. This is a sign of raised intracranial tension and can occur in coma due to any cause.

b) Kussmaul breathing: manifests as a deep, sighing and rapid breathing at a regular rate and is suggestive of metabolic acidosis.

c) Central pontine hyperventilation: Term used for the deep and regular breathing that occurs in rostral brainstem damage due to reticular pontine infarction or in central brainstem dysfunction secondary to herniation. Interspersed deep sighs or yawns may precede the development of this respiratory pattern.

Hyperventilation: comatose conditions associated with hyperventilation are:

  • Metabolic acidosis
  • Diabetic ketoacidosis
  • Raised intracranial tension
  • Bacterial meningitis Renal failure Pneumonia Liver failure Brainstem lesions

Head, Neck and Spine

Should be thoroughly examined for any evidence of head injury and for any abnormality of the following:

  • Head circumference
  • Anterior fontanelle
  • Sutures

Look for bruits or dysraphisms, transillumination of the skull must be done in young infants in coma.

Ear

  • Blue discoloration of the ear drum: basilar skull fracture
  • Ecchymosis over the mastoid process: fracture base of skull. (Battle sign)
  • Head circumference
  • Anterior fontanelle
  • Sutures

Nose

  • Epistaxis: head injury, deranged coagulation with intracranial haemorrhage

Tongue

  • Laceration of tongue: tonic/clonic seizures
  • Coated furry tongue: chronic renal failure

Signs of Trauma

  • Ecchymosis over long bones: fracture
  • Disolouration of flanks and periumbilical region: blunt trauma abdomen
  • Severity of injury more than degree of trauma reported; child abuse

Skin

Some dermatological findings may help in clinching the diagnosis.

  • Flushing: hypercarbia, atropine poisoning
  • Rash: measles, other viral exanthemata, bacterial endocarditis
  • Pigmentation: pellagra
  • Changes in turgor: dehydration
  • Uremic frost: chronic renal failure
  • Petechiae: meningococcal septicemia
  • General erythema: atropine poisoning

Examination of the Central Nervous System

Signs of Meningeal Irritation

  • Meningitis (a) Bacterial (b) Aseptic (viral)
  • Sub-arachnoid haemorrhage
  • Cerebral Malaria
  • Intra – cranial haemorrhage

Pupils

Look for size, shape, reaction to light and accommodation.

  • Pontine lesions: pinpoint pupils
  • Thalamic lesions: anisocoria
  • Transtentorial herniation: Hutchison’s pupil (ipsilateral constriction followed by dilatation and subsequently contralateral constriction and dilatation)
  • Poisoning:

    1. Fixed and dilated pupils: Sympathomimetic drugs, deep ether anaesthesia
    2. Constricted pupils: Narcotics, anticholinergics, phenothiazines, sodium valproate.

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