Pediatrics · MU Sofia

30. Comatose status

Covers coma as a state of unarousable unresponsiveness and why it arises from brainstem, hemispheric or diffuse metabolic and toxic causes. It sets out the AVPU scale and a paediatric Glasgow Coma Scale table with separate columns for older children and infants, then groups causes into a table. Further sections address bedside clues from the neurological examination, signs of raised intracranial pressure, investigations, emergency management, outcome, and a closing note on dental hazards in unconscious children.

Inside: 6 sections · 3 tables · 16 flashcards · 5 min

Topic 30 of 30 in the MU Sofia syllabus for Pediatrics (Medicine, Year 5). The free AceMed note covers it in 6 sections, about 491 words (5 min of reading), with 16 flashcards.

In this note

  1. Introduction
  2. Measuring the level of consciousness
  3. Causes
  4. Assessment
  5. Investigations
  6. Management

Introduction

Coma is a state of unarousable unresponsiveness: the child cannot be woken and does not respond meaningfully to stimuli. Consciousness needs both arousal (brainstem reticular activating system) and awareness (both cerebral hemispheres), so coma means either a lesion in the brainstem, damage to both hemispheres, or a diffuse metabolic or toxic process. In children, most coma is metabolic, toxic or infectious rather than structural.

Measuring the level of consciousness

AVPU: Alert, responds to Voice, responds only to Pain, Unresponsive. “P” or “U” roughly equals a GCS of 8 or less: the airway is at risk.

GCS 8 or below = coma: protect the airway.

Assessment

  1. ABC first, then D: GCS or AVPU, pupils, posture. Don't Ever Forget Glucose (DEFG): check bedside glucose at once.
  2. History: onset (sudden: bleed, seizure, toxin; gradual: infection, tumour, metabolic), fever, headache, vomiting, trauma, medicines and poisons at home, diabetes, epilepsy, shunt, previous episodes, family history.
  3. Examination: temperature; purpuric rash (meningococcal disease); neck stiffness, bulging fontanelle; smell (ketones, alcohol); signs of injury or abuse; liver size; blood pressure.

Clues from the neurological examination

Signs of raised intracranial pressure: falling GCS, headache and vomiting, bulging fontanelle, abnormal pupils, abnormal posture, and the late Cushing triad (hypertension, bradycardia, irregular breathing). Papilloedema may be absent in acute rises.

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