Resuscitation - Coma

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of acute coma in a resuscitation.

Background

• The unconscious and unresponsive child is a very serious and potentially life threatening situation
• The key to treatment is quick stabilisation and treatment of life threatening events, then careful but quick evaluation of the cause and treatment of reversible causes
• Any child with a VP shunt with decreased conscious state should be assumed to have a shunt blockage and raised intra-cranial pressure until proven otherwise
• Senior emergency doctor or specialist (e.g. ICU or anaesthetics) help is usually warranted and should be considered early
• Trauma
• Sepsis
• Seizures/post ictal
• Ingestion
• Endocrine and Electrolyte abnormalities.

Assessment

Assessment of conscious level

• Two scales which are readily assessable and recordable are the:
• AVPU
• A – Alert/Awake
• V – Repsonds to voice
• P – Responds to painful stimuli
• U – Unresponsive/Unconscious
• Glasgow Coma Scale (GCS) (modified for children).

Modified Glascow Coma Scale

		< 1 year	1 - 4 years	> 5 years
Eyes  Open	4	Spontaneous
	3	To speech and touch
	2	To pain
	1	No response
Best  Verbal Response	5	Normal vocal sounds, cries, periods of quiet wakefulness	Alert – word or phrases of usual ability	Orientated, appropriate words and phrases to usual ability
	4	Spontaneous irritable cries	Less than usual words, spontaneous irritable cry	Confused/disorientated
	3	Cries to pain only	Cries or vocal sounds to pain only	Inappropriate words
	2	Moan, grimace/facial movement to central pain	Occasional whimper or moan to pain	Incomprehensible sounds
	1	No response	No response	No response
Best Motor Response	6	Moves spontaneously and purposefully	Obeys commands/usual movements	Obeys commands/usual movements
	5	Localises to stimuli	Localises to painful stimulus	Localises to painful stimulus
	4	Withdraws in response to pain	Withdraws in response to pain	Withdraws in response to pain
	3	Responds to pain with abnormal extension	Abnormal flexion	Abnormal flexion
	2	Responds to pain with abnormal extension	Abnormal extension	Abnormal extension
	1	No response	No response	No response

History

• Past history particularly the presence of Ventriculo-peritoneal (VP) shunt
• Recent injuries especially head injuries
• Progress of unconsciousness – sudden or slowly progressive deterioration
• Fever
• Headaches (and onset of headaches – abrupt or progressive)
• Neck stiffness
• Vomiting
• Medications that might have been accessible.

Investigations

Investigations and blood tests are likely to be needed unless diagnosis is absolutely clear.

Consider:

• Glucose (don’t ever forget glucose)
• Blood gas (arterial or venous)
• FBC
• UEC
• Calcium
• Blood cultures (if febrile or sepsis is considered a possibility)
• CT head - likely to be needed, but make decision in consultation with senior clinician
• EEG – rarely needed as an acute investigation, but consider in non-convulsive status (in consultation with neurology)
• Blood alcohol level and urine drug screen.

Management

Any patient who scores a P in the AVPU or less than 9 on the Glascow Coma Scale requires airway support.

Resuscitation

Airway + C-Spine Immobilisation Assess adequacy and ensure there is no obstruction Have a low threshold for early intubation Breathing Support with oxygen and assisted ventilation if needed Beware of hypoventilation and rising CO2 - causes raised intracranial pressure Circulation Assess for signs of shock (slow capillary refill, hypotension) and treat appropriately Disability Rapid neurological assessment If seizures occurring or non-convulsive status thought likely refer to Status epilepticus Glucose Early evaluation of blood glucose level (BGL) If BGL low give 2mL/kg of 10% glucose If BGL >11 mmol/L refer to Diabetic ketoacidosis Collect growth hormone/cortisol/insulin levels if glucose is low Seek the cause of the coma

Potential causes

• Trauma
  
  • Accidental or non accidental
• Hypoxic-ischaemic injury
  
  • Cardiorespiratory arrest, shock syndromes, near-drowning, smoke inhalation
• Intracranial Infection
  
  • Meningitis, Encephalitis, Post-infectious
• Mass lesion
  
  • Haematoma, abscess, tumour
• Fluid, electolytes, acid-base
  
  • Hypernatraemia, hyponatramia, acidosis/alkalosis
• Epilepsy disorders
• Systemic infection
  
  • Sepsis syndrome, septic encephalopathy
• Complications of malignancy
• Poisoning
• Acute Ventricular Obstruction
• Vascular
  • Arteriovenous malformations, embolism, venous thrombosis, arteritis homocysteineuria
• Hypertensive encephalopathy
• Endocrine dysfunction
  • Hypoglycaemia
  • Diabetes mellitus
  • Diabetes insipidus
• Respiratory failure
• Renal failure
• Hepatic encephalopathy
• Reye's syndrome
• Inherited metabolic disorders
  • Lactic acidosis
  • Urea cycle disorder
  • Aminoacidopathies
• Hypothermia, hyperthermia
• Iatrogenic
  • Overcorrection of acidosis
  • Overhydration
  • Drug overdose.

Bibliography

1. Teppas JJ Paediatric Trauma TRAUMA 5th edition 2004 McGraw Hill Companies
2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
3. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier

Endorsed by:	Executive Director, Medical Services	Date:	Oct 2021
		Review date:	Jul 2022

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