Coma and Convulsion

Learning objectives

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

C represents “Coma and Convulsion”. In the ABCCCD system

The following signs indicate impaired neurological status: coma, lethargy, and convulsions.

Key fact for providers – how to assess the NYI for coma and convulsion
(AVPU)

To help you assess the conscious level of a child a simple scale (AVPU) is used:

A Is the baby Alert? If not,

V Is the baby responding to Voice? If not,

P Is the baby responding to Pain? (rub the sternum)

U The baby who is Unresponsive to voice (or being shaken) AND to pain is Unconscious.

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 ranges of median prevalence are the following: hypoxic-ischaemic encephalopathy (HIE): 38-48%; hypoglycaemia: 3-7.5%; hypocalcaemia: 2.3-9%; central nervous system (CNS) infections:e.g. meningitis 5.5-10.3% (7).

Initial management of coma and convulsions

COMA CONVULSION
Manage the airway Manage the airway
Position the child Position the child
Consider an airway Check the blood sugar
Check the blood sugar Give IV glucose if low
Give IV glucose if low Give anticonvulsant if still seizing

You have to observe the infant carefully.

Comparing tetanus and convulsions

Tetanus Convulsions
Conscious Unconscious
Increases with tactile stimulation, wind, light and noise Does not change in response to stimulation

Treatment of coma and convulsion

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

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.

Algorithms for managing convulsions < 2 weeks and > 2 weeks Wall charts

Key fact for providers

  • Rectal administration is quicker than placing an IV line in an emergency.
    When giving rectal medication hold the buttocks together for a few minutes to stop it running out.
    Give rectal injections using a 1 or 2ml syringe. Rectal diazepam acts within 2 to 4 minutes.

  • Wait 10 minutes between medications to see if the child has stopped fitting.
    Seek help of a senior or more experienced person, if available.

  • Diazepam and phenobarbitone can both affect the NYI’s breathing, so it is important to reassess the airway and breathing regularly and have a bag and mask of correct size available.

  • Do not give oral medication until the convulsion has been controlled (danger of aspiration).

Doses anticonvulsants

Dose of Phenobarbitone for young infants

Inj. Phenobarbitone intravenous dose (200mg/ml)
Dose is 20mg/kg
Weight of Infant Initial dose Repeat dose
2kg or less 0.2ml 0.2ml
2 to 4kg 0.3ml 0.3ml

Dosage of diazepam

Diazepam given rectally 10mg/ 2ml solution
Age/ weight Dose 0.1ml/kg
2 weeks to 2 months (<4kg) 0.3ml

May cause respiratory arrest

Paraldehyde Dosage

Paraldehyde given rectally 10mg/ 2ml solution
Age/ weight Dose: 0.2ml/kg IM, 0.4ml/ kg PR;
Injection 10 ml ampoules
2kg 0.4mls IM or 0.8mls PR
3kg 0.6mls IM or 1.2mls PR
4kg 0.8mls IM or 1.6mls PR

Do not leave in plastic syringe for longer than 10-15 min