Paediatrics: Altered level of consciousness: management

Altered level of consciousness: management

Investigations

Consider the following if the cause of the coma is unknown.

Blood

·  FBC, clotting, and bleeding time.

·  Glucose, electrolytes, urea, liver function tests, ammonia, and lactate.

·  Save two extra tubes of clotted blood for storage in the laboratory.

Toxicology

·  Urine, blood, gastric aspirate for ingestions.

·  Serum lead and free erythrocyte protoporphyrin.

Acid–base 

Arterial blood gas.

Microbiology 

Blood and urine cultures.

Imaging

·  Cranial CT scan.

·  MRI particularly for posterior fossa or white matter lesions. Cranial imaging should only be performed if the child is well enough to leave the emergency department, i.e. a full assessment has been undertaken, and the child is stable, or intubated if GCS<9

Electroencephalography Standard EEG.

Lumbar puncture

Defer LP until a CT scan has been obtained if there are signs of raised ICP or focal neurology, and until after intubation if GCS<9. Examine CSF for microscopy, culture, glucose, and protein.

Meningitis

·  20–20,000 white blood cells (WBC)/mm³ with a polymorphonuclear neutrophil leucocyte predominance.

·  An elevated protein level >100mg/dL.

·  Low glucose <2mmol/L (or <50% of plasma level).

Encephalitis

·  20–1000cells/mm³ with lymphocyte predominance.

·  The presence of red blood cells (RBC) up to 500 cells/mm³ suggests herpes simplex virus (HSV) infection.

·  CSF protein can be normal or mildly elevated.

·  Glucose is usually normal (770% of plasma level).

Monitoring

The form and type of monitoring will be dictated by the underlying cause of the patient’s state. Generally, after initial evaluation, monitor hourly:

·  Vital signs, pupil reaction, fluid balance.

·  The GCS for neurological review—in those with GCS 9–11 a gastric tube and urinary catheter may be needed.

Treatment

Follow a standard protocol

·ABC: the initial priority.

·Glucose: whenever the cause of coma is not clearly obvious, 25% glucose (250–500mg/kg) should be given IV after a blood sample has been taken for laboratory blood glucose testing.

·  Specific therapies should be considered.

Antibiotics

Antimicrobial therapy is often given presumptively. The choice will de-pend on local epidemiology, public health, immunization, and antibiotic policy. In the comatose child, consider the following.

·Age <4 weeks: group B streptococcus, Gram –ve bacteria, and Listeria monocytogenes: Recommend: ampicillin + aminoglycoside.

·Infants 1–3 months: group B streptococcus, Gram-negative bacteria, Streptococcus pneumoniae, Neisseria meningitides. Recommend: ampicillin + aminoglycoside/3rd generation cephalosporin.

·>3 months: Streptococcus pneumoniae, Neisseria meningitides.

Recommend: 3rd generation cephalosporin.

In the comatose older child where no CSF is available, a combination of antimicrobials to cover HSV, Streptococcus pneumoniae, and Mycoplasma pneumoniae infection is often prescribed.

·Cefotaxime (IV 50mg/kg qds; maximum 12g/day).

·Erythromycin (IV 10mg/kg qds).

·Aciclovir (IV 10mg/kg, tds).