2. Learning Objectives
At the end of the session you will be able to:
• Assess and document the level of consciousness
• Assess and treat a child with coma
• Assess and treat hypoglycaemia
• Assess and treat a convulsing child
• Recognise and treat common causes of coma and
convulsion
3. AVPU
All children that are convulsing are U
Coma is an AVPU of P or U
The airway is at risk for children with an AVPU of P or U
A: Alert
V: Responsive to Voice
P: Responsive to Pain
U: Unresponsive
4. AVPU
• Alert:
Rub your knuckles gently on the child's
sternum; child will push the hand away
Not responding or faintly groaning
instead of reacting to pain
Child looking around and responsive to
environment
Turns head or opens eyes to mother's call
• Unresponsive:
• Voice:
• Pain:
6. Systematic Approach to Disability
• Safety Stimulate Shout Setting
• Airway: airway positioning, jaw thrust, adjunct, recovery position
• Breathing: additional support and oxygen
• Circulation: assess and give fluids as per guidelines
• Disability:
• AVPU
• Check and treat blood glucose
• Check and treat convulsions
7. Systematic Approach to Disability
Other symptoms to consider:
• Temperature
• Photophobia (does not like light)
• Rash
• Neck and limb stiffness
• Bulging fontanelle
8. Hypoglycaemia
• Hypoglycaemia is low blood glucose (sugar)
• Many definitions of hypoglycaemia exist
ETAT+ uses < 3.0 mmol/l
(or <2.2mmol/l in neonates)
9. Why is Hypoglycaemia Important?
• Hypoglycaemia is common: it affects about 1 in 12
children admitted to hospital
• Glucose (sugar) is required for all cells to function.
• Hypoglycaemia leads to irritability, lethargy, coma and
convulsions
• Associated with increased risk of death and permanent
brain damage
• Quick blood sugar correction = reduced damage to brain
and other vital organs
10. When to Treat Hypoglycaemia
• There are no reliable signs of hypoglycaemia
• Consider in any unwell child with reduced
consciousness or who has not been feeding well
• Check blood sugar with glucometer if available
• Blood sugar <3.0mmol/l means hypoglycaemia
• If a glucometer is not available, assume and treat
hypoglycaemia if AVPU <A (i.e. V or P or U)
11. Treatment of Hypoglycaemia
• If there is no IV access, consider oral or NG
sugar if the child is responsive enough:
• Oral sugar under the tongue
• Oral 10% dextrose
• Nasogastric 10% dextrose
• IO access for 10% dextrose
5ml/kg of 10% Dextrose IV
12. Hypoglycaemia in Children with SAM
• If child is conscious, give sugary fluid to drink or
by NG
• 50mls of 10% dextrose
• Or 1 teaspoon of sugar dissolved in 3.5 tablespoons of
water
• If child is unconscious and unable to take oral
feeds, give IV 10% Dextrose 5ml/kg
13. Hypoglycaemia in Neonates
• If baby is able to feed, give breast or NG feed immediately
• If unable to feed, give IV 10% Dextrose 2ml/kg
• Re-check sugar after 30 minutes
• Then feed more frequently e.g. every 2 hours
Hypoglycaemia in neonates is <2.2mmol/L
14. Maintain the Blood Sugar after Bolus
• Re-check the blood sugar after dextrose
bolus if possible about 30 minutes later
• Maintain blood sugar by either:
• More frequent feeds – oral or NG
• IV maintenance fluids containing dextrose
15. How to make 10% Dextrose
50% dextrose is NOT
recommended for IV injection
16. How to make 10% Dextrose
with Water/Saline + 50% Dextrose
4 parts Water for injection 1 part 50% Dextrose
Water 50% Dextrose
10 ml syringe 8 ml 2 ml
20 ml syringe 16 ml 4 ml
50 ml syringe 40 ml 10 ml
17. How to make 10% Dextrose
with 5% Dextrose + 50% Dextrose
9 parts 5% Dextrose 1 part 50% Dextrose
5% Dextrose 50% Dextrose
10 ml syringe 9 ml 1 ml
20 ml syringe 18 ml 2 ml
50 ml syringe 45 ml 5 ml
18. Approach to a Convulsing Child
• Safety Stimulate Shout Setting
• Airway
• Breathing
• Circulation
• Disability
• AVPU = U if convulsing
• Check or just treat hypoglycaemia
• Then treat the convulsion
19. When to Treat Convulsions
Child is convulsing for 5 minutes or longer
or
More than 2 short convulsions in 2 hours
Give medicines to stop convulsions when:
20. Treatment of Convulsions
Diazepam 0.25 mg/kg IV or 0.5 mg/kg PR
Phenobarbitone 15mg/kg IM/IV
or Phenytoin 15 mg/kg IV (if not already loaded)
5 mins after start
of convulsion
Wait 10 minutes to see if effective
Check or treat low blood sugar
Diazepam 0.25 mg/kg IV or 0.5 mg/kg PR
Wait 10 minutes to see if effective
15 mins after start
of convulsion
25 mins after start
of convulsion
21. Giving Rectal Diazepam
4-5 cm
inside the
anal margin
All of the
barrel of a
2mls syringe
and nearly
all of a 1ml
syringe
22. Medications for Seizures
• Diazepam, Phenobarbitone and Phenytoin can
slow and even stop a child’s breathing
• Maximum safe doses in 24 hours seems to be
2 x Diazepam doses plus Phenobarbitone loading
• Giving Phenobarbitone
• Give by deep IM injection or slow IV infusion (max
1mg/kg/min = 15mins for phenobarbitone loading dose)
• Phenobarbitone or Phenytoin must not be given by
IV bolus
23. Further Management of Convulsions
• Give IV Ceftriaxone (100mg/kg) and IV
Artesunate if not already given in the last
24 hours
• Place in recovery position
• Perform full set of vitals including
temperature
• Ensure child is receiving appropriate
maintenance fluid or feed
24. Causes of Coma and Convulsions
Cerebral malaria – covered in separate lecture
Hypoglycaemia – already discussed
Meningitis
• Bacterial or viral infection of the meninges (layers of
tissue around the brain and spinal cord)
• Presentation: neck stiffness, photophobia, headache,
convulsions, fever, limb stiffness, bulging fontanelle.
• Lumbar puncture should NOT delay treatment
• Treatment: IV Ceftriaxone 100mg/kg once daily
25. Causes of Coma and Convulsions
Febrile Convulsions
• Convulsion associated with fever
• Affects children 6 months to 5 years
• Short convulsions usually stop on their own within 5
minutes
• Generalized seizure then recovers completely and rapidly
• Identify the cause of the fever and treat appropriately
27. Summary
• SSSS ABCD is the correct first approach to a child with
coma or convulsion
• The AVPU scale can be used to assess and document the
level of consciousness
• Don’t forget to check the blood sugar. If you cannot check
the blood sugar and the child is convulsing or has an
AVPU <A, be safe and give 10% dextrose.
• Treat convulsions that last over 5 minutes or if there are
more than 2 convulsions in 2 hours with diazepam and
phenobarbitone if required
• Hypoglycaemia, malaria and meningitis are common
causes of convulsions
