Paediatric Coma - Paediatrics Emergency Management

Paediatric Coma

·        Assessment: Coma scales – main function is to assess progress

o  AVPU scales

o  Glasgow scale (but designed for adults)

o  Child Coma scale

·        General observation:

o  Alert states:

§  Fully alert (what this mean depends on age of child)

§  Confused

§  Delirium: agitated and confused

o  Reduced alertness:

§  Lethargic: fails to maintain wakefulness without stimulation

§  Obtunded: drifts into sleep unless constantly woken

§  Stuporose: unconscious but withdraws to painful stimuli 

§  Comatose: fails to respond.  May be decorticate or decerebrate.  At risk of airway failing

·        Differential in children:

o   Hypoxic: respiratory or circulatory failure

o   Epileptic seizures

o   Trauma: intracranial haemorrhage, brain swelling

o   Infections: meningitis, encephalitis

o   Poisons 

o   Metabolic: Renal, hepatic failure, Reye‟s syndrome, hypoglycaemia, diabetes, hypothermia, hypercapnea

o   Vascular lesions: bleeding, AV malformations, arterial or venous thrombosis

o   Hypertension

·        Diagnosis:

o   Must be bilateral cortex or brainstem involvement

o   Is it focal, multifocal or diffuse

o   Is it getting better or worse

o   Metabolic disturbances (including hypoxia and seizures) account for 90% of unconscious children

o   Supratentorial mass lesions compressing the brain stem: 3^rd nerve palsy and dilated pupil on same side – NOT 6^th nerve palsy

o   Subtentorial lesions affecting the brain stem directly: slow pulse, high BP, irregular breathing

·        Management:

o   Stabilise vital functions: ABC then DEFG

o   Complete history: esp trauma, poisoning, previous diseases – diabetes, epilepsy

o   Exam: vital signs and progression, trauma, neck stiffness, CNS function, and:

§  Verbal responsiveness 

§  Ocular responses: eye opening, papillary responses and spontaneous eye movement, ocular reflexes (eg Dolls eye) 

§  Respiratory patterns: Cheyne Stokes (rate slows down, stops, restarts), irregular, apnoeas, stridor

§  Motor system: Motor responses, reflexes, tone, posture

o   Investigations:

§  Blood: gases, electrolytes, glucose, FBC, LFT, ammonia, calcium, lactate, clotting factors

§  Urine: poisons, sugar, organic acids, ketones

§  Chest Xray, consider skeletal survey

§  ECG

§  CT Scan 

§  LP only when safe: risk factors – prolonged fits, focal neuro signs, purpuric rash, CGS < 13, dilated pupils, reduced Dolls Eye, abnormal posture, signs of herniation, coagulation disorder, papilloedema, hypertension