Coma

Common causes

Hypoxia/ shock Any cause
Infections Malaria, meningitis, encephalitis, cerebral abscess (parasitic, bacterial, viral, mycobacterial, fungal) - check HIV status
Seizures Overt/ subclinical seizures, post ictal
Trauma Head injury, non-accidental injury
Metabolic Hypoglycaemia, hyperglycaemia, electrolyte imbalance, renal failure, liver failure
Poisoning Opiates, salicylates, alcohol, organophosphates, benzodiazepines
Tumours Intracerebral, brainstem
Vascular Haemorrhage, thrombosis, hypertension, vasculitis
Other Psychogenic

Important points in history

Associated symptom May indicate diagnosis of
Cough, vomiting, fever, rash Encephalitis, meningitis
Dog bite, unusual behaviour, fluctuating coma Rabies
Profuse D+V Dehydration, electrolyte imbalance
Cough, dyspnoea Hypoxia
Poor feeding, malaria (especially infant) Hypoglycaemia
Polyuria, polydipsia, vomiting Hyperglycaemia
Oliguria, haematuria, oedema Renal failure
Jaundice, bleeding, fever, vomiting Liver failure

Important points in examination

AB
Respiratory pattern: may be irregular due to brainstem lesion or raised intracranial pressure. May be rapid due to acidosis or drug ingestion

C
Pulse:
Bradycardia suggests raised intracranial pressure or organophosphate poisoning
Blood pressure: Hypertension suggests raised ICP

D
Blantyre coma score (BCS):

Motor: localises (2) withdraws (1) none (0)
Verbal: appropriate cry (2 ) inappropriate (1) none (0)
Eyes: follows (1) does not follow (0)

Relevant investigations

Indications for admission

Treatment

Call for help whenever uncertain

Seizures

Fluids

Antimalarials

Antibiotics

Other definitive management

Other treatment will be guided by the history and clinical findings:

Supportive Care

Nutritional Support

Other Supportive Care

Monitoring

A comatose child should be monitored at least 4 hourly by a nurse and twice a day by a doctor.

Blood pressure should be checked if it were previously abnormal or the child has deteriorated

Complications

Acute complications

Chronic complications

When to Discharge