This document provides guidance on approaching and managing a child presenting with coma. It outlines the key steps as: 1) initial stabilization of airway, breathing, and circulation, 2) obtaining a thorough history and physical examination including neurological assessment, 3) performing investigations to identify the cause, 4) ongoing monitoring and management focusing on treating raised intracranial pressure, seizures, and metabolic abnormalities, and 5) specific treatment of potential infections or toxic exposures while maintaining supportive care measures. The prognosis depends on the underlying cause but younger children with higher GCS scores on presentation generally have better outcomes.

1. APPROACH TO A
CHILD WITH COMA
DR C ABHIRAM KUMAR
SPECILAIST-PICU
ASTER CMI HOSPITAL

2. O INTRODUCTION
O ETIOLOGY-CLUES AND CUES
O EXAMINATION
O INVESTIGATION
O MONITORING AND MANAGEMENT

3. O Consciousness- State of being awake
and aware of self and surroundings
O Arousal- Requires intact RAS
O Awareness – Requires intact cerebral
hemispheres

5. O Coma- Complete absence of arousal and
awareness of self and environment lasting
> 1hour.
O Coma is a life threatening Pediatric
emergency

6. Approach to the comatose
child
O Initial stabilization- ABCD’s
O Airway- Positioning of the child
Clearing of secretions
Insertion of airway

7. O Breathing- Assess adequacy of breathing
Supplemental O2 with NRM
Ventilation(Bag and
mask/tube)
O Circulation- Assess circulatory status
IV/Intraossoeus cannulation
Fluid bolus/Inotropes

8. O Disability- Dextrostix, Correct
hypoglycemia
Control seizures
C-spine stabilization
Identify and treat raised ICT
Intubate if GCS<8

9. O History
O Physical Examination
O Neurological Examination

14. History
O Fever
O Rash
O Travel to another place
O Seizures
O Behavioral disturbances
O Trauma
O Exposure to toxins
O Animal bites
O Past medical illness
O Family history

15. Examination of Vitals
O Fever
O Tachycardia/Bradycardia
O Tachypnea/Altered breathing pattern
O Hypertension/Hypotension

16. General physical examination

17. Neurologic Examination
O Level of consciousness
O Pupillary abnormalities
O Breathing patterns
O Posture and motor response
O Signs of Raised ICP
O Herniation syndromes

19. Pupillary Abnormalities

21. Motor Response
O Appropriate Response- Withdrawal from
the painful stimulus
O Inappropriate Response- Decorticate or
Decerebrate posturing
O Flaccidity with absent response-ponto –
medullary or lower brainstem lesion

23. Signs of Raised ICT
O Headache
O Vomiting
O Bradycardia
O Hypertension
O Irregular breathing
O Papilledema
O 3rd or 6th cranial nerve palsy
O Impairment of consciousness

24. Herniation Syndromes

26. Investigations

28. Management
O Stabilize ABC’s
O Identification and treatment of raised ICP
O Neuroprotective measures
O Treat seizures and continuous EEG
monitoring
O Correction of acid base and electrolyte
abnormalities
O Maintain normothermia and euvolemia

29. Specific Management
Infections
O LP for CSF analysis and culture
O RT PCR/ME panel for encephalitis
O Store 2 extra samples of CSF always
O If LP contraindicated- Emperical
Antibiotics(Cefftriaxone+/- Vancomycin)
O Acyclovir for viral encephalitis
O Antimalarial(Artesunate/Quinine) in
endemic areas

30. ROLE OF STEROIDS
O Useful in- ADEM
Meningococcemia with shock
Enteric Encephalopathy
Tubercular meningitis
Pyogenic meningitis
Autoimmune Encephalitis
Raised ICP with localised
edema

31. O Antidotes for poisonings
O Treat metabolic causes appropriately

32. Prognosis
O Depends on cause of altered mental
status
O Infectious encephalopathies have better
prognosis
O Recovery of motor skills is better
compared to cognitive deficits
O Younger children with lower GCS scores
who present in hypotension tend to have
porer outcomes

33. Summary
O Pediatric coma is an acute medical
emergency which needs prompt evaluation
and intervention
O Stabilize ABC’s while simultaneously
evaluating with effective history and accurate
physical examination
O Regardless of etiology general principles of
management must be followed to improve
neuronal recovery and outcome