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Coma - management in the intensive care setting

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Definition

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 
Eye opening  4
3
2
1
spontaneous
to shout
to pain
none
spontaneous
to speech
to pain
none
Best motor response 6
5
4
3
2
1

normal movement
localizes pain
flexion withdrawal 1
flexion - abnormal (decorticate)
extension (decerebrate)
none

obeys command
localizes pain
flexion withdrawal
flexion - abnormal (decorticate)
extension (decerebrate)
none
    0 - 23 months 2 - 5 years  > 5 years 
Best verbal response2 5
4
3
2
1
smiles / coos / cries appropriate
cries / screams consolable
irritable / inconsolable
grunts / agitated
none
appropriate words / phrases
inappropriate words
cries / screams
grunts
none
orientated
confused response
inappropriate words
incomprehensible
none

1   apply knuckles to sternum and observe arms
2   arouse patient with painful stimulus if necessary

Management

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
    • hypoxaemia
    • hypercarbia
  • 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.

Investigations

FBC Consider coagulation screen
Glucose If hypoglycaemic measure insulin, blood ketones, growth  hormone and cortisol
Urea & electrolytes  
Blood gas  
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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Document Control

  • 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