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37: Neurological Emergencies

Nicholas Irwin; Roger L. Humphries

IMMEDIATE LIFE-THREATENING NEUROLOGICAL CONDITIONS

THE COMATOSE CHILD

GENERAL CONSIDERATIONS

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.
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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

aThe appropriate number from each section is added to total between 3 and 15. A score less than 8 usually indicates CNS depression requiring positive-pressure ventilation.

bIf no modification is listed, the same response applies for both infants and children.

(Reproduced, with permission, from Hay WW, Levin MJ, Deterding RR, Abzug MJ, Sondheimer JM (eds): Current Diagnosis & Treatment: Pediatrics, 21st ed. McGraw-Hill, Inc., 2012. Copyright © McGraw-Hill Education LLC.)

Table 37–2.Common causes of coma.
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Table 37–2. Common causes of coma.
Likely Cause
Mechanism of Coma Newborn Infant Older Child

Anoxia

Asphyxia

Respiratory obstruction

Severe anemia

Birth asphyxia, HIE (hypoxic ischemic encephalopathy)

Meconium aspiration, infection (especially respiratory syncytial virus)

Hydrops fetalis

Carbon monoxide (CO) poisoning

Croup, tracheitis, epiglottitis

Hemolysis, blood loss

Ischemia

Cardiac

shock

Shunting lesions, hypoplastic left heart

Asphyxia, sepsis

 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 ...

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