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Coma is a symptom, not a diagnosis.

The aim of immediate management is to minimise any ongoing neurological damage whilst making a definitive diagnosis. Elements of the history, examination, investigation and treatment will therefore occur simultaneously.

Immediate management

• Attend to airway, breathing and circulation - (see  Resuscitation guidelines).
• If traumic cause is possible immobilise cervical spine and arrange urgent neurosurgery involvement (see  Major Trauma and  Head Injury guidelines).
• Insert i.v. line.
• Perform blood glucose; if glucometer < 2.5 mmol/l in a non-diabetic, send specific bloods tests, administer i.v. dextrose (see Hypoglycaemia guidelines).
• Consider naloxone 0.1 mg/kg (max. 2 mg) i.v. ± repeat.
• Assess and monitor pulse, respiratory rate, BP, temperature, oximetry ± ECG monitoring and conscious state.
• Look carefully for subtle signs of a continuing convulsion (see  Convulsions guidelines).

History and examination

Onset and duration of symptoms.

Past history - seizures, diabetes, adrenal insufficiency, infection, cardiac, previous similar episodes (metabolic conditions).

In the presence of	Consider
Scalp bruising or haematoma	Head injury
Inconsistent history, retinal haemorrhage	Non-accidental injury
Fever, seizures	Meningitis, Encephalitis
Focal neurological signs Focal seizures Papilloedema Asymmetric pupils	Focal intracerebral pathology, eg. Tumor
Shunted hydrocephalus	Blocked shunt
Renal disease	Hypertensive encephopathy

Consider NAI in any infant who presents with an unexplained encephalopathy.

Investigations

In the light of the possible diagnosis consider these investigations:

• full blood examination
• urea and electrolytes
• glucose
• liver function test
• arterial blood gas
• urine drug ± metabolic screen
• urine antigens
• culture of blood and urine
• ammonia
• cortisol
• coagulation screen
• ECG

Ongoing care

• Will be determined by the diagnosis, level of consiousness and degree of ventilatory and circulatory support needed.
• See  poisoning /  adrenal crisis /  meningitis /  major trauma guidelines if diagnosis becomes clear.

Lumbar puncture, imaging and antibiotics:

• See  Lumbar puncture guideline
• See  flowchart

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