Evaluation of the comatose child
Etiologies of coma
Trauma
- Parenchymal injury
- Intracranial hemorrhage (epidural, SDH, SAH)
- Diffuse Axonal Injury
Nontraumatic
- Toxic/metabolic
- HIE (shock, cardiopulm arrest, near-drowning)
- Toxins
- Medications: narcotics, sedatives, antiepileptics, antidepressants, analgesics, aspirin
- Environmental toxins: organophosphates, heavymetals, cyanide, mushroom poisoning
- Illicit substances
- Systemic metabolic disorders
- Substrate deficiencies (hypoglycemia, cofactorssuch as thiamine, niacin, pyridoxine)
- Electrolyte and acid-base imbalances
- DKA
- Thyroid/adrenal/other endocrine disorders
- Uremic or hepatic coma
- Reye syndrome
- Inborn errors of metabolism (urea cycle defect,amino acidopathies, mitochondrial disorders)
- Infections (Meningitis, encephalitis)
- Inflammatory (Sarcoidosis, Lupus cerebritis)
- Mass lesions (neoplasms, abscess, hydrocephalus)
- Paroxysmal neurologic disorders (seizures, migraines)
- Vascular
- Intracranial hemorrhage
- Arterial infarcts
- Venous sinus thromboses
- Vasculitis
Initial evaluation of coma
- ABC’s: assessment and stabilization
- Ensure adequate ventilation & oxygenation
- BP monitoring
- Draw labs: Glucose, lytes, ammonia, blood gas, LFTs, BUN/Cr, CBC, lactate, pyruvate, and toxicology screen
- Head CT
- Neuro assessment
- GCS score
- Assess for raised intracranial pressure / herniation
- Assess for focal neurologic disease
- Assess for history or signs of seizures
- If concern for infection, give broad spectrum antibiotics
- Consider LP prior to abx if no delay in doing procedure
- Consider antidotes for specific toxic exposures
- Identify and treat critical elevations in intracranial pressure
- Neutral head position, HOB 30 degrees, sedation
- Hyperosmolar therapy (Mannitol, 3% NaCl, 7% NaCl)
- Hyperventilation as temporary measure
- Consider intracranial monitoring
- Consider neurosurgical intervention
- Seizure prophylaxis / treatment
- Consider EEG
- Detailed history and physical
- MRI if concerns for stroke
Glascow coma scale
Eye openingVerbal ResponseMotor Response
| Eye opening | Verbal Response | Motor Response |
| Spontaneous 4 To command 3 To pain 2 None 1 |
Oriented 5 Confused 4 Disoriented/ inappropriate words 3 Incomprehensible sounds 2 None 1 |
Obeys commands 6 Localizes pain 5 Withdraws 4 Abn flexion to pain 3 Abn extension 2 None 1 |
*Adapted from Roger’s Handbook of Pediatric Intensive Care, 4th Edition