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Emergent evaluation and management of stupor and coma in children

Emergent evaluation and management of stupor and coma in children
Evaluation
  • Vital signs and general and trauma examination
  • Neurologic examination and GCS
  • Fingerstick blood glucose
  • Blood gas (arterial or venous)
  • Screening laboratories (CBC, glucose, electrolytes, BUN, creatinine, blood and urine cultures, LFTs, urinalysis, urine drug screen)
  • Head CT scan: do urgently if focal neurologic signs, papilledema, or fever; consider rapid MRI instead if available
  • Lumbar puncture: do urgently after CT scan if fever, elevated WBC, meningismus; otherwise, do according to level of suspicion for diagnosis or if cause remains obscure
  • Other laboratory tests: for metabolic conditions*, coagulation tests, carboxyhemoglobin, specific drug concentrations; do according to level of suspicion for diagnosis or if cause remains obscure
  • EEG: for possible nonconvulsive seizure, or if diagnosis remains obscure
  • Brain MRI with DWI, if cause remains obscure
Management
ABCs:
  • Intubate if GCS ≤8 or respiratory failure
  • Stabilize cervical spine
  • Supplement O2
  • IV access
  • Blood pressure support as needed
Treat hypoglycemia identified on fingerstick. Dextrose 0.25 g/kg (2.5 mL/kg of 10% dextrose solution) after blood glucose drawn, before results back; do NOT delay pending results.
Treat definite seizures. Initial treatment with lorazepam (0.1 mg/kg, maximum single dose 4 mg). If seizures continue treat as for status epilepticus.
Empiric treatments
For suspected infection:
  • Ceftriaxone 100 mg/kg (maximum single dose 2 grams) and vancomycin (age-specific dose)
  • Acyclovir (age-specific dose)
For suspected ingestion:
  • Naloxone 0.1 mg/kg IV in patients up to 20 kg or ≤5 years; maximum 2 mg IV (use if opioid toxidrome: miosis, respiratory depression, hypotonia)
For suspected increased ICP:
  • Mannitol 0.5 to 1 g/kg IV;
  • or
  • Hypertonic saline 3% 5 mL/kg

Also, elevate head and keep midline
For suspected nonconvulsive status epilepticus:
  • Lorazepam (0.1 mg/kg, maximum single dose 4 mg). If suspicion of seizures continues, treat as for status epilepticus.
  • Fosphenytoin (10 to 20 PE equivalents/kg). If suspicion of seizures continues, treat as for status epilepticus.

BUN: blood urea nitrogen; CBC: complete blood count; CT: computed tomography; DWI: diffusion-weighted imaging; EEG: electroencephalography; GCS: Glasgow coma scale; ICP: intracranial pressure; IV: intravenously; LFT: liver function tests; MRI: magnetic resonance imaging; PE: phenytoin equivalents; WBC: white blood cells.

* Please refer to UpToDate topics on stupor and coma in children and toxic metabolic encephalopathy in children.
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