Starship Children’s Health Clinical Guideline

Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

• Definition • Emergency Management of Raised
• Causes Intracranial Pressure
• History • Further Investigations
• Examination • Criteria for Admission to PICU
• Where is the Lesion? • References
• Management

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 spontaneous spontaneous

3 to shout to speech
2 to pain to pain
1 none none

Best motor 6 normal movement obeys command

Response 5 localizes pain localizes pain
1
4 flexion withdrawal flexion withdrawal
3 flexion - abnormal (decorticate) flexion - abnormal (decorticate)
2 extension (decerebrate) extension (decerebrate)
1 none none

0 - 23 months 2 - 5 years > 5 years

Best verbal 5 smiles / coos / cries appropriate words / orientated
2
response appropriate phrases
4 cries / screams inappropriate words confused response
consolable
3 irritable / inconsolable cries / screams inappropriate words
2 grunts / agitated grunts incomprehensible
1 none none none

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

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 1 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

Causes
Cerebral hypoxaemia/ Severe anaemia, apnoea, asphyxiation, carbon monoxide poisoning, drowning,
ischaemia respiratory failure, shock (adrenal crisis, cardiogenic, septic, hypovolaemic),
cerebrovascular event.

Epilepsy Post-ictal state, status epilepticus

Infectious diseases Encephalitis, meningitis, septic shock

Raised intracranial Mass lesions (abscess, empyema, haemorrhage or pressure tumour), cerebral
oedema, hydrocephalus, malfunction of a ventriculo-peritoneal shunt

Metabolic and endocrine Diabetic ketoacidosis, hypoglycaemia, hypernatraemia, hyponatraemia,

disorders hypocalcaemia, hypomagnesaemia, liver failure, renal failure (uremia), inborn errors of
metabolism

Toxic Substance abuse (alcohol, hallucinogens, opiates, volatile agents), clonidine,

paracetamol, prescription drugs, salicylates, lead, other

Trauma Concussion, cerebral contusion, intracranial haemorrhage, cerebral oedema

(remember shaken infant syndrome)

Other Acute confusional migraine, psychiatric

History
• Time-course of changes in mental state (behavior, feeding, schoolwork)
• Past and recent medical history (including medications)
• Family history (for example, of epilepsy or migraine)
• Drugs or toxins present in the house
• History of head trauma.

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 2 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

Examination
Examination
Do not assess for meningeal irritation unless cervical spine trauma is unlikely or has been
excluded. A complete physical examination is essential. Do not forget:

Cardiovascular Blood pressure, pulse rate and rhythm, peripheral perfusion

Neurological Posture, evidence of a ventricular shunt, level of consciousness, localising signs, pupillary
responses, examination of the fundi, signs of trauma to the head

Respiration Colour (cyanosis), rate and pattern of breathing

Skin Abnormal pigmentation, anaemia, bruising, jaundice, needle marks, petechiae, sweating

Smell Alcohol, glue, ketones, “bitter almonds” (cyanide), phenol

Temperature Hypothermia or hyperpyrexia

Suspect raised ICP if there is a GCS score < 9; abnormal vital signs (hypertension,
bradycardia, abnormal respiratory pattern); fixed dilated pupils; decerebrate / decorticate
posturing; or status epilepticus unresponsive to standard therapy. (see Emergency
Management of Raised ICP)

Where is the Lesion?

It is difficult to differentiate supratentorial from infratentorial lesions unless localising brainstem
signs precede the onset of coma.
Supratentorial Focal hemispheric signs, progression of signs from head to foot, Cheynes-
Stokes respiration (diencephalon: hyperpnoea alternating with apnoea),
decorticate posture (arm flexion and leg extension), unilateral pupil constriction
and a Horner syndrome (hypothalamus), unilateral fixed dilated pupil (temporal
lobe herniation)

Infratentorial Dilated pupils with poor response to light (if no mydriatic given), midposition
fixed pupils (midbrain), small reactive pupils (pons), Horner syndrome (lateral
medullary lesions), abnormal respiratory pattern, cranial nerve palsies,
negative ice water caloric test / doll’s eye, decerebrate rigidity (generalised
extension of trunk and limbs)

Metabolic Changes in mental state precede motor signs, motor signs are symmetrical,
pupillary reactions are preserved, disturbed acid-base is common, seizures or
abnormal motor movements are common

Toxic Pinpoint pupils (narcotics, barbiturates, some mushrooms, organo-

phosphates, phencyclidine),
Dilated ± unresponsive pupils (atropine, amphetamine, calcium channel
blockers, cocaine, cyanide, digoxin, ergotamine, ethanol, LSD, neuroleptics,
tricyclic antidepressants)

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 3 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

Management
Airway Protect and maintain. Use airway adjunct (oropharyngeal, nasopharyngeal,
LMA) or intubate if unable to maintain airway.
If GCS < 9 and clinical circumstances do not suggest improvement imminent
then intubation is indicated to secure airway.

Breathing Give oxygen until saturations known, monitor O2 saturation, assess rate and
pattern of breathing. Support breathing by hand bagging if required.
Supplemental oxygen is indicated for hypoxia, but should not be given
routinely to comatose children with normal circulation & oxygen saturation.

Circulation Obtain venous access. Assess for signs of shock and treat as indicated (see
guidelines on shock)
The aim of fluid therapy in raised ICP is to maintain adequate cerebral
perfusion pressure (CPP).
CPP = Mean arterial pressure – Intracranial pressure
Resuscitation of the circulation takes priority over fluid restriction & osmotic
therapy. These treatments should not be commenced until after adequate fluid
resuscitation to restore a perfusing blood pressure

Dextrose Aim to avoid both hyper and hypoglycaemia

Check blood glucose level. If low, take blood for hormones (insulin, hGH,
cortisol) and ketones and give a bolus of 10% Dextrose 5 ml/kg IV, followed by
a 10% Dextrose infusion at 4 ml/kg/hour (7 mg/kg/min) with close monitoring of
glucose.
If high, consider diabetes

Drugs If opiates suspected, consider Naloxone 0.1-0.8 mg /kg IV (maximum dose 2

mg) – particularly if respiratory depression.
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
Acyclovir and cefotaxime should be administered acutely if encephalitis or
meningitis is a possibility.

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 4 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

Emergency Management of Raised

Raised Intracranial Pressure
i.e. GCS < 9 and Cushing’s triad of hypertension, bradycardia, abnormal respiration (gasping,
irregular, sporadic) and / or fixed, dilated pupil(s)

Airway Oxygenate and intubate

Ventilate Avoid hypercapnoea, aim to maintain a pC02 of 4.5 to 5.0 kPa

Osmotic therapy Use 3% NaCl – give 3 ml/kg IV given as a rapid infusion (e.g. over 5 to 10
minutes)
or
Use Mannitol – 0.5g to 1.0g/kg (2.5 to 5ml/kg of 20% Mannitol)
Will need to place a urinary catheter

Sedation and pain For example morphine and midazolam

relief

Elevate head To 30°

Control fever Give Paracetamol intragastrically or rectally 10 -15mg/kg q 4 hrly

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 5 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

Further Investigations
FBC Consider coagulation screen

Glucose If hypoglycaemic measure insulin, blood ketones, growth hormone and cortisol
A laboratory or blood gas analyser glucose is required for confirmation of the
bedside testing result, but do not delay treatment of symptomatic
hypoglycaemia awaiting this result.

Urea & electrolytes

Blood Gas

Urinalysis Consider toxicology screen of urine and blood

Liver function tests Consider serum ammonia

CT Head +/- contrast (discuss with Radiology)

Lumbar puncture Contra-indicated in presence of coma (GCS <9), raised intra-cranial pressure
or unstable clinical state. If meningitis is suspected but LP is contra-indicated,
start antibiotics

Cervical spine imaging Protect neck until injury has been excluded by standard criteria in cases of
trauma or possible trauma. It is often not possible to exclude cervical spine
injury in a comatose child.
May need to CT upper cervical spine in trauma

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.

PICU should be involved early for a child who clearly meets these criteria. A child requiring a CT
scan and admission to PICU should be transferred and monitored in CT by the PICU team.
Responsibility for children not requiring PICU admission will by the CED team with Anaesthetist
involvement as required for CT, and subsequent referral as appropriate.

A child who needs ongoing circulatory or respiratory resuscitation should not be

transferred from CED to anywhere other than PICU or the operating theatres – they should
not be moved to CT.
Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 6 of 7
 Starship Children’s Health Clinical Guideline
Note: The electronic version of this guideline is the version currently in use. Any printed version can
not be assumed to be current. Please remember to read our disclaimer.

COMA (THE UNCONSCIOUS CHILD)

References
• Avner JR. Altered States of Consciousness. Peds in Rev 2006;27:331-337.
• Kirkham FJ. Non-traumatic coma in children. Arch Dis Child 2001;85;303-312.
• Wong CP, Forsyth RJ, Kelly TP, Eyre JA. Incidence, aetiology, and outcome of non-
traumatic coma: a population based study. Arch Dis Child 2001;84;193-199.

Author: Drs Liz Segedin/Richard Aickin/Mike Shepherd Service: Children’s Emergency Dept.
Editor: Dr Raewyn Gavin Date Issued: Reviewed August 2007
Coma (The Unconscious Child) Page: 7 of 7