The document provides guidance on assessing and managing an altered sensorium in a child. It describes stabilizing the child's airway, breathing, and circulation. It also recommends treating potential causes like hypoglycemia, infections, seizures and raised intracranial pressure. The primary goals are saving the child's life and achieving intact neurological recovery through a multidisciplinary approach.

1. Approach
To a child
With
Altered Sensorium
Dr.G.Sudhakar M.D(peds);D.C.H;
Professor Of Pediatrics(Rtrd)
Consultant Pediatrician
KIMS Hospitals
Kurnool

2. Objectives
• Familiarize ourselves with COMA and related terms
• Pathophysiology of coma
• Approach to assessment
• Approach to investigations
• Approach to treatment
• Aggravating issues , how to deal with?
• Goals of treatment
• Prognosis

3. Various terms of Altered sensorium
• Consciousness (Intact arousal… ARAS and intact Awareness… cerebral cortex)
… both cortex, ARAS and brainstem intact
• Lethargy, obtundation, stupor ( sleepy , awareness is less severely impaired ) …
cortex < ARAS impaired… brainstem intact
• Delirium (hyperactive & hypoactive) looks awake but completely unaware of
surroundings… cortex > ARAS impaired, brain stem intact
• Coma ( Awakeness and Awareness … both are lost) cortex, ARAS grossly
impaired, Brain stem intact
• Awakeness and Awareness are affected to varied levels in these clinical
situations and all the terms mean Altered Sensorium/Altered mental status
only and hence no need to differentiate practically.
• May recover, may die, progress to Brain death, transforms into MCS, PVS )
• Brain death ... classic triad of Coma, Apnea and absent brainstem reflexes
• MCS…as sequalae ( intact brain stem & minimal response is elicitable to a
stimulus)
• PVS …as sequalae ( intact brain stem & no response to any stimuli )

4. Rule-out Coma mimics
• Complete paralysis / Locked in syndrome
• Akinetic mutism / Abulia
• Catatonia and psychiatric unresponsive ness

5. Anatomy of COMA ( Encephalopathy)
and pathophysiology
• Toxic
encephalo
pathy
• Epileptic
encephalo
pathy
• Metabolic
encephalo
pathy
• Organic/
structural
encephalo
pathy Cerebral
cell ,
ARAS,
inter
connect
Cell
environ
Toxics
Genetic
abnorm
al cell

6. Likely issues with altered sensorium
• 1.Postural tone is lost… falls…injuries? Scene safety?
• 2.Loss of communication… Rescuers help?
• 3.Loss of oropharyngeal and glosso - pharyngeal muscle
tone… tongue falls back into throat causing UAO…
• 4.Loss of protective throat reflexes … pooling of saliva (0.5-
1ml/kg/hour) in throat and subsequent Aspiration…
• 5.Autonomic instability… loss of balance between sympathetic
and parasympathetic functions… vasomotor centre instability
and poor response to vasoactive agents
• 6.Vital centers affected… loss of cardiorespiratory drive.

7. A 3 yrs old Irfan is rushed into PEMD?
Mother on the way to hospital.
• Initial impression ( visual and auditory clues )
• Appearance : Hypo/ Hypertonic, no interaction, no cry, no
looks/gaze, no speech
• Breathing : Normal, shallow, RD, noises with breathing(
gurgling ), no breathing
• Color : pale, bleeds, skin spots, flushed, mottled etc…
• Any one abnormality in any sphere is a sign of life-threatening
problem .

8. Life-threatening problem.
What to do now?
Continue Assessment or Intervene?
• For any suspected life-threatening problem
• EAI cycle to be followed
• Examined ABC
• Assessed as Life threatening problem
• Intervene now?
Examine
Assess
intervene

9. Stabilize ABC
• Airway : positioning, cleared the airway, and secure the
airway with non-invasive ( if maintainable) or invasive
measures ( if not maintainable) Intubated (RSI)
• Breathing : supplemental oxygen if spontaneous
breathing is adequate, and Assisted breathing if
spontaneous breathing is inadequate.( connected to
ventilator)
• Circulation : Gain IV/IO access, obtain blood sample for
Lab, finger prick Glucose ( 50mg% … so corrected with
0.5ml/kg of 10%D ), connected to cardiac monitor, if
needed fluid boluses, vasoactive infusions.

10. What to do after initial stabilization?
“Classify the physiological status”
by
• Primary assessment : To know
Respiratory status
Circulatory status
Neurological status

11. Primary assessment
(ABCDE approach)
• 1.Airway : already taken care of
• 2.Breathing : already taken care of
• 3.Circulation: PR 134bpm, PV normal, CRT 3sec,
peripheries warm, temp 39 degrees C. BP 96/54mm
of Hg, MAP of 68mm of Hg
• 4.Diisability : U/AVPU, GCS 7, tone increased, PCD of
both eyeballs upwards and to right, OCR intact,
pupils are small and reactive.
• 5.Exposure : undressed, temp 39 degrees C.

12. At the end of Primary Assessment
• Respiratory status : intubated and secured
• Circulatory status : Stable ( no signs of shock)
• Neurological Status : Coma ( GCS 7) with active focal
seizures.
• Treat active seizures : Benzodiazepines followed by
phenytoin as per status- epilepticus protocol
• Treat fever ( paracetamol rectal suppository )
• Until now we assessed and performed some clues-
based interventions as needed.
• Watch for Raised ICP in every child with altered
sensorium and GCS score of <12.
• GCS of 12 or <12, is a neuro emergency and raised
ICP very likely?

15. Raised ICP( >20mm of Hg)
(ICP 2-5 in infants, 3-7 young children, 10-15 older children)
• Clinical
• Imaging
CT Midline shift
Effaced basal cisterns
Effaced sulci
Thumb printing
Optic sheath diameter
Ocular US
<1 year 5.2mm
> 1 year 5.8mm
• Direct measure EVD / Intra cerebral cath
• >20mm of Hg
• >5 minutes is persistent

16. Managing raised ICP
• Measures in ER/PICU
Rapid correction of
Hypoxia
Hypercarbia and
Hypotension (CPP= MAP-ICP)
( MAP = CPP + ICP )
<5years 40-50mm of Hg and
>5 years 50-60 of mm-6Hg.
MAP of 60-70mm of Hg in <5yrs
. 70-80mm of Hg in >5yrs
( Fluids & vasoconstrictors)
General measures
Head end elevation to 15-30
degrees
Head in midline
Normal Temp, Glucose,
Thiamine (MVI) in SAM
Hb >7gm%
Prophylactic AED
Control pain and agitation
General Nursing measures
Nutrition, fluids and electrolyte
disturbances
Avoid vasodilators, Ketamine,
5%D, Propofol

18. 160

19. ( Never )

20. ( + osmotic agents )

22. To know the cause of altered sensorium
Get clues from History and physical examination
• Secondary assessment : SAMPLE history and Focused
Head to Toe physical examination (Fever + 2days,
irritable 1day, had one FS at 18months of age.)
• Focused neuro and clues-based physical examination
GCS trends
Brainstem reflexes
Motor responses
Head to toe screen

23. Clues from History
• Recurrence, vomiting and FTT s/o Metabolic
• Jaundice, melena s/o Hepatic encephalopathy
• Edema, oliguria s/o Hypertensive encephalopathy or uremic
encephalopathy
• vomiting, loose stools s/o HUS, hypovolemia.
• Birth anoxia, Developmental delay s/o seizures.
• Endemicity, epidemics s/o AES.
• H/o preceding VE s/o ADEM
• Family h/o open TB or epilepsy
• H/o immune compromised state s/o TBM, HIV, opportunistic
infections
• Response to Thiamin, Glucose and calcium

24. Clues from physical examination
• Repetitive multifocal myoclonic jerks s/o Metabolic,
Anoxic and Toxic encephalopathies
• FND s/o focal lesions
• Flaccidity s/o loss of cortical and brainstem functions
• Decorticate and decerebrate posturing s/o bilateral
cortical and midbrain lesions.
• Mild altered sensorium with asterixis, no FND and intact
brain stem reflexes often s/o Metabolic encephalopathy
• Loss of brain stem reflexes s/o Brain death
• Papilledema s/o raised ICP or Hypertension
• Choroid tubercles s/o TBM
• Retinal bleeds in AES s/o JE and poor prognosis

25. Diagnostic investigations
• Must for all :
• General : CBC, UA, SGOT and SGPT, urea and creatinine,
cultures of blood and urine
• Organic : Neuro-imaging, LP
• Metabolic : ABG, Lactate, Electrolytes, Ca, Mg, Glucose
• Toxic : Toxic screening ( blood and Urine )
• Epileptic : EEG monitoring

26. What are clues-based investigations ?
• Metabolic profile if persistent acidosis with increased anion
gap
• Serum Ammonia
• Specific drug profiles if suspicious
• Pseudo-cholinesterase levels if OPC poisoning is suspected
but history is unyielding
• Coagulation profile if IC bleeds
• CTD profile if SID/AID/vasculitis is a clinical possibility
• Repeat tests as need based

31. Consultations …
• Be in continuous touch and in coordination with your
Pediatric intensivist
• Neurologist consultation for persistent altered
sensorium or if fresh neurological signs appearing
• Nephrology services for MODS involving kidney
• NS consultation for any SOL
• Endocrinologist services may be sought as needed
• General pediatrician should take a central leadership
role and coordinate services of required

32. Goals of interventions
• Saving life of the child.
• Intact neurological survival
• Measures to prevent recurrence.

33. Diagnostic Algorithm
Altered sensorium
Initial Impression & Primary assessment
Stabilize ABC,
Glucose , Thiamin
Secondary assessment & Diagnostic testing
Infective Non-Infective
CBC, LP, CT/MRI, ABG,
Electrolytes, EEG
CT/MRI, ABG, Ammonia,
Clues based tests, CSF
AES
+/- Metabolic issues
( hypo/hyper natremia
Hypo calcemic, hypo magnesia,
hypoxia, hypercarbia,
Cytokine storm etc.)
+/- structural issues on imaging
(disease specific findings,
Complications, unrelated focal lesions, ADEM)
+/- NCSE
Structural
Neoplasms, AVM, ICH,
genetic, calcifications, etc.
Metabolic
IEM, hepatic, uremic etc.
Toxic
OPC, Drugs, Lead etc.
Epileptic
Genetic, secondary
Vasculitis

34. Causes of altered sensorium
• Infections : Pyogenic meningitis
AES, ADEM, cerebral malaria
Rickettsia, Lyme disease,
Brain abscess, subdural empyema
Sepsis
• Toxidromes : OPC
Kerosene
Drugs
Lead
AED

35. Causes contnd…
• Metabolic disturbances :
Hypoglycemia, DKA
Dyselectrolytemia
Uremic, Hepatic encephalopathy
IEM
• Endocrinal :
Adrenal insufficiency
Hypoparathyroidism
Thyroid disorders

36. Causes contnd…
• Head injury (TBI) : Concussion, contusion,
Diffuse Axonal Injury
ICH ( EDH, SDH, ICH, SAH )
• Epileptic : Post ictal, SE
• Increased ICP : ICSOL, Brain abscess
Hydrocephalus, ICH.
• Reyes syndrome

37. Causes contnd…
• Vascular : CVT, AVM, ICH
Emboli
Vasculitis
• Hypertensive encephalopathy
• Hypoxic ischemic injury : Hypotension, cardiac arrest, cardiac
arrhythmias, near drowning
• Psycho-social : CA&N (NAT)

38. Summary of
Managing a comatose child
• Airway
• Breathing
• Circulation
• Glucose, calcium, MVI
• Raised ICP
• Seizures
• General Nursing Care
• Multi disciplinary
coordination
• Infection
• Temperature control
• Acid base status
• Fluids, Electrolyte
disturbances and
Nutrition
• Antidotes
• Agitation

39. Prognosis
• COMA can last for 2-4 weeks
• Good prognosis in Toxidromes
• Worst prognosis with Hypoxic Ischemic Injury
• Variable with Infective
• Variable with TBI
• GCS- lower the score worse the prognosis
• Quality of supportive and Nursing care matters
between life and death

40. Thank you