Coma and Convulsions (Chapter 16)

Learning Objectives

After completion of this chapter the participant should be able to:

• Describe the assessment (AVPU) of a NYI in a coma.
• Describe the management of a NYI in a coma.
• Describe the assessment of a NYI with a convulsion.
• Describe the stepwise management of a NYI with a convulsion.

C represents Coma and Convulsion in the ABCCCD system.

The following signs indicate impaired neurological status:

• Coma
• Lethargy
• Convulsions

How to assess for convulsions

This assessment depends on your observation of the child and the history from the parent. Children who have a history of convulsion, but are alert and not currently convulsing, need a complete clinical history and investigation, but no emergency treatment for convulsions. Sometimes, in infants, the seizures are subtle, jerky movements may be absent, but there may be twitching (abnormal facial movements), apnoea, lip smacking, or abnormal movements of the eyes, hands or feet.

Among neonates with seizures, the reported causes and ranges of median prevalences are the following: hypoxic-ischaemic encephalopathy (HIE): 38-48%; hypoglycaemia: 3-7.5%; hypocalcaemia: 2.3-9%; central nervous system (CNS infections: 5.5-10.3% (7).

Comparing Tetanus and Convulsions

Management of Coma and Convulsion

Treatment of coma and convulsion are similar and will be described together.

Management of Convulsion

To manage the airway of a convulsing child, gentle suction of secretions should be done, the infant put on his side, and oxygen started. Do not try to insert anything in the mouth to keep it open.

You have to observe the infant carefully

Initial Management of Coma and Convulsions

Algorithm for Managing Convulsions

Infant from birth up to 2 weeks of age with seizures

NB. The volumes in the chart above assumes that the phenobarbitone being used is of 200 mg/ml preparation. The dose is actually 20mg/kg and should be recalculated if the vial concentration is different.

Managing seizures beyond 2 weeks of age

NB. The volumes in the chart above assumes that the phenobarbitone being used is of 200 mg/ml preparation. The dose is actually 20 mg/kg and should be recalculated if the concentration is different.

Loading Dose of Phenobarbitone for Young Infants

Inj. Phenobarbitone intravenous dose (200 mg/ml) dose is 20 mg/kg.

Or calculate as phenobarbitone loading dose 20 mg/kg IV. Phenobarbitone to be given IM and not IV.

Dosage of Diazepam

• Diazepam given rectally using a 10 mg/2 ml solution.

Or calculate as rectal diazepam 0.4mg mg/kg/dose.

Diazepam may cause respiratory arrest – DO NOT GIVE IN BABIES <2 WEEKS.

Paraldehyde Dosage

• Paraldehyde preferable to give rectally.

Do not leave in plastic syringe for longer than 10-15 min and paraldehyde should not be given IV. All drug dose calculations must be carefully checked because drug ampoules may come in different strengths.