Coma

Causes

Emergency management

Glasglow Coma Scale

Clinically

Investigations

CT scan brain

Treatment

Management of cerebral oedema

Pupils reactions

The most common causes of impaired level of consciousness in children include head injuries, CNS infections, post-ictal states, ingestion of toxins and metabolic disturbances. 

Causes

• Infections (meningitis/encephalitis) 
• Hypoxic ischaemic events (shock/near drowning) 
• Post ictal (seizures) 
• Trauma (remember NAI) 
• Ingestion (toxin/drug/alcohol) 
• Acute hypertension 
• Metabolic (Diabetic ketoacidosis; hepatic failure; electrolyte abnormalities, inborn errors of metabolism) 
• Vascular (intracranial bleeding/AVM’s) 
• Tumours 

Emergency management 

1. Airway 
2. Breathing 
3. Circulation 
4. Disability (AVPU!) 
5. Don’t ever forget glucose 

Airway: Ensure patent and maintains – if no gag or cough or a “P” on AVPU score – intervention is needed. 

Breathing: Supplemental oxygen. Ensure adequate respiratory effort. If not, then intubation and ventilation is needed. Observe the pattern of respiration – acidotic or Kussmaul breathing may help with diagnosis. 

Circulation: Ensure good blood pressure – insert IV lines and take bloods at the same time – especially check serum glucose level! 

Disability: Assess conscious level, posture, pupil responses. Don’t ever forget glucose. 

AVPU score: (A = Alert V = verbal response P = responds to pain U = unresponsive) 

Glasgow Coma Scale 

Clinically

• History is important: (fever/rashes/toxins/trauma/granny’s pills/TB). 
• Look for rashes. Measure the temperature. 
• Look for any neck stiffness 
• Look for localising signs (pupils/gaze palsy/tone/reflexes) 
• Assess circulation. Look for signs of shock. 
• Measure blood pressure. Check glucose. 
• Signs of raised ICP (papilloedema may be late sign). 

Investigations

• FBC/U&E/Calcium/Magnesium/Phosphate/blood culture/glucose (+/- ketones)/Blood Gas 
• Drugs/Toxins - Toxicology screen, including tricyclics and organophospates (pseudocholinesterase assay) 
• CRP – if elevated it may be sign of infection, inflammation 
• Coagulation screen - if bleeding or petechial rash 
• Consider LFT’s and ammonia sent on ice and arrange with Lab before taking blood. Heparanised (dark green top) tube. Has to go to Greenpoint lab. 

DO NOT LP a child with decreased level of consciousness. 

CT Scan Brain

Should be done on any child with coma, especially if not improving or has localising signs. 

Treatment

• Emergency management as above 
• If obvious underlying cause treat accordingly 
• If associated with fever/neck stiffness then treat with: 
• Ceftriaxone 100 mg/kg IV daily 
• Dexamethasone 0,15 mg/kg 6-hrly 
• If herpetic lesions: Acyclovir 10mg/kg/dose q8h and omit dexamethazone 
• If ?TBM (TB contact/CXR suspicion/FTT): TBM regime 

Signs of raised intercerebral pressure / cerebral oedema: 

Posture decorticate or decerebrate, abnormal pupillary responses, abnormal breathing patterns, Cushing’s Triad of ↓ HR, ↑BP & Kussmaul breathing, persistent or rapid decrease in LOC. 

For urgent management

• Notify the consultant, admit to high care or ICU and treat with cerebral protective measures. 
• Will usually require CT Brain once stabilised. 

Management Cerebral Oedema 

1. Elevate head of bed 30°, head in midline 
2. Maintain PaCO2 3,5 – 4,5kPa, intubate and ventilate if necessary. 
3. Supplemental oxygen. 
4. Ensure good blood pressure. 
5. Ensure normothermia, Rx fever aggressively. 
6. Mannitol 0,5 – 1 g/kg IV over 30min to 1 hr. Only if normotensive. May repeat x1. Check for crystallisation before administration. Monitor urine output. 
7. Dexamethasone if space occupying lesion: 1-2mg/kg IV loading dose stat (Max 10mg), and 0.25mg/kg/dose q6h IV (Max:16mg/day) for 48 hours then taper over 5 days. 
8. For use of hypertonic saline (3% NaCl), discuss with ICU at tertiary centre. 

Pupils reactions