Coma - management in the intensive care setting
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A state of unrousability. The changes in mental state which
precede coma may be classified by the "Modified Glasgow Coma Scale
For Infants And Young Children"
In this scale, the total score = eye opening + motor response + verbal response. The best response is scored. The lowest score is 3, and the highest is 15 (the fully conscious child). Children in coma have GCS scores of 8 or less. In the context of head trauma, a GCS of 8 or less suggests severe cerebral injury, a GCS of 9 - 12 moderate cerebral injury, and a GCS of 13 - 15 minor cerebral injury.
Limitations of the GCS include the fact that the verbal component is difficult to apply to young children and cannot be applied to the intubated patient. The score does not give any weight to focal deficits such as hemiparesis. The score was developed in adults, and does not have the same predictive value in childhood.
|Category||Score||Response < 1 year||Response > 1 year|
|Best motor response||6
flexion - abnormal (decorticate)
|0 - 23 months||2 - 5 years||> 5 years|
|Best verbal response2||5
|smiles / coos / cries appropriate
cries / screams consolable
irritable / inconsolable
grunts / agitated
|appropriate words / phrases
cries / screams
1 apply knuckles to sternum and observe
2 arouse patient with painful stimulus if necessary
|Airway||Protect and maintain. Use oropharyngeal airway or intubate if unable to maintain airway|
|Breathing||Give oxygen until saturations known, monitor O2 saturation, assess rate and pattern of breathing. Support breathing by hand bagging if required|
|Circulation||Obtain venous access. Assess for signs of shock and treat as indicated|
|Glucose||Check blood glucose level. If low, take blood for hormones (insulin, hGH, cortisol) and ketones and give a bolus of 10% Glucose 5 ml/kg IV, followed by a 10% Glucose infusion at 4 ml/kg/hour (7 mg/kg/min). If high, consider diabetes|
|Drugs||If opiates suspected, consider Naloxone 0.1-0.8 mg /kg IV (maximum dose 2 mg). Avoid Flumazenil, which may induce convulsions in mixed overdoses, particularly if tricyclic antidepressants have been taken. Isolated benzodiazepine overdose does not cause significant respiratory depression and children are best managed with simple observation. If you decide to use Flumazenil, the dose is 5 μg / kg IV. You can repeat this every minute to a total of 40 μg / kg (maximum dose 2 mg)|
|Specific therapy||After stabilisation a rapid approach to diagnosis is imperative so that specific therapy can be given. See guidelines for the management of poisoning and specific conditions, and consult the National Poisons Centre for specific toxins|
Criteria for admission to PICU
- Inadequate airway protection
- Unstable vital signs
- Respiratory compromise:
- irregular pattern of breathing
- Glasgow Coma Scale ≤ 13
- The Coma Score must be taken in the context of the possible diagnosis. A child with a GCS of 13 who is post-ictal after a febrile seizure would be regarded differently from a child whose GCS is falling 4 hours after a head injury.
|FBC||Consider coagulation screen|
|Glucose||If hypoglycaemic measure insulin, blood ketones, growth hormone and cortisol|
|Urea & electrolytes|
|Urinalysis||Consider toxicology screen of urine and blood|
|Liver function tests||Consider serum ammonia|
|Lumbar puncture||Contra-indicated in presence of coma (GCS <9), raised
intracranial pressure or unstable clinical
state. If meningitis
is suspected but LP is contra-indicated, start antibiotics
|Xray cervical spine||Protect neck until fracture has been excluded by lateral cervical spine films in cases of trauma or possible trauma|
If history, examination and the above investigations do not provide a diagnosis, or if they suggest raised intracranial pressure, an urgent CT scan is mandatory. If CT scan is normal, consider neurological consultation and urgent EEG.
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- Date last published: 31 October 2005
- Document type: Clinical Guideline
- Services responsible: Paediatric Intensive Care Unit
- Owner: Anusha Guneshalingham
- Editor: John Beca
- Review frequency: 2 years
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