Coma in Pediatric Emergency

Coma is a symptom, not a diagnosis. The aim of management is to minimise any ongoing neurological damage. History, examination, investigation and treatment will be simultaneous.

Immediate resuscitation and management

The primary assessment should be as for any seriously ill child. A structured approach to the primary survey is particularly important; if a problem is found during the initial ABCDE assessment, then immediate treatment and resuscitation should start, remembering to treat the treatable as you progress through the primary survey.

Supporting an inadequate airway, ineffective breathing or compromised circulation should reduce the likelihood that the reduced conscious level is secondary to hypoxia and fluid loss and of any further deterioration of conscious level due to these two mechanisms. Thus, you must clear and protect the airway and assist the breathing as necessary. If a traumatic cause for the symptoms is likely, immobilise the cervical spine and arrange urgent neurosurgery-involvement.

Check the pulse and insert an intravenous line and perform a blood sugar test; if blood glucose is less than 2.5 mmol 1 −1 in a person who is not diabetic, send specific blood tests  and administer 10% dextrose i.v., 5 ml/kg weight bolus. Consider naloxone, 0.1 mg/kg weight (max 2mg) if pupils are small. Assess and monitor pulse, respiratory rate, BP, temperature, oximetry and conscious state. Consider signs of raised intracranial pressure and look for subtle signs of continuing convulsions.

History and examination

Consider the onset and duration of symptoms. Is there a past history? Relevant conditions include seizures, diabetes, adrenal insufficiency, infection and cardiac problems. Other signs and symptoms may suggest the cause of the coma (Figure 1).

Figure 1: Cause of Coma in Pediatric

Investigations and further management

Consider these investigations in the light of the possible diagnoses, if not already done:

• full blood examination

• urea and electrolytes

• glucose

• liver function

• arterial blood gas

• urine drug ± metabolic screen

• urine antigens

• blood and urine culture

• ammonia

• cortisol

• coagulation screen

• ECG

Investigation and management of coma

Figure 2 shows the investigation and management of coma. It is important that raised intracranial pressure is always excluded before lumbar puncture in all cases.

Figure 2: investigation and management of coma

Figure 2 Lumbar puncture, imaging and antibiotics in coma. Abbreviations:CT, computed tomography; EEG electroencephalogram; ICP, intracranial pressure; LP, lumbar puncture; MRI, magnetic resonance imaging.

Ongoing care

Continue to assess and support the airway, breathing and circulation. Care will depend on the diagnosis, level of consciousness and degree of ventilatory and circulatory support required. Consider an early transfer to a pediatric intensive care unit.