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Altered level of consciousness: management
Consider the following if the cause of the coma is unknown.
· 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.
· Urine, blood, gastric aspirate for ingestions.
· Serum lead and free erythrocyte protoporphyrin.
Arterial blood gas.
Blood and urine cultures.
· 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.
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.
· 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).
· 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).
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.
·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.
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).
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