IMMEDIATE LIFE-THREATENING NEUROLOGICAL CONDITIONS
A rapid and systemic approach to assessment and management of coma in the pediatric patient is of paramount importance guided by initial clinical evaluation. Careful monitoring and continuous reassessment are necessary. The initial assessment should be performed at the same time as initial basic medical therapy such as placement of monitoring devices and intravenous access.
Coma is characterized by decreased levels of arousal and may be graded by clinical findings. The Glasgow coma scale (GCS) is a common and easily used scale in the adult patient and may be adapted to pediatric use (Table 37–1).
The most common cause of coma in children is infectious, and rapid management of potential infectious causes is recommended (Table 37–2).
Table 37–1.Pediatric Glasgow coma scale. ||Download (.pdf) Table 37–1. Pediatric Glasgow coma scale.
|Eye opening response |
|Spontaneous ||4 |
|To speech ||3 |
|To pain ||2 |
|None ||1 |
|Verbal response: Child (Infant modification)a |
|Oriented (Coos, babbles) ||5 |
|Confused conversation (Irritable cry, consolable) ||4 |
|Inappropriate words (Cries to pain) ||3 |
|Incomprehensible sounds (Moans to pain) ||2 |
|None ||1 |
|Best upper limb motor response: Child (Infant modification)b |
|Obeys commands (Normal movements) ||6 |
|Localizes pain (Withdraws to touch) ||5 |
|Withdraws to pain ||4 |
|Flexion to pain ||3 |
|Extension to pain ||2 |
|None ||1 |
Table 37–2.Common causes of coma. ||Download (.pdf) Table 37–2. Common causes of coma.
| ||Likely Cause |
|Mechanism of Coma ||Newborn Infant ||Older Child |
Birth asphyxia, HIE (hypoxic ischemic encephalopathy)
Meconium aspiration, infection (especially respiratory syncytial virus)
Carbon monoxide (CO) poisoning
Croup, tracheitis, epiglottitis
Hemolysis, blood loss
Shunting lesions, hypoplastic left heart
|Shunting lesions, aortic stenosis, myocarditis blood loss, infection |
|Head trauma (structural cause) ||Birth contusion, hemorrhage, non-accidental trauma (NAT) ||Falls, auto accidents, athletic injuries |
|Infection (most common cause in childhood) ||Gram-negative meningitis, enterovirus, herpes encephalitis, sepsis ||Bacterial meningitis, viral encephalitis, postinfectious encephalitis, sepsis, typhoid, malaria |
|Vascular (CVA or stroke, often of unknown cause) ||Intraventricular hemorrhage, sinus thrombosis ||Arterial or venous occlusion with congenital heart disease, head or neck trauma |
|Neoplasm (structural cause) ||Rare this age. Choroid plexus papilloma with severe hydrocephalus ||Brainstem glioma, increased pressure ...|