Coma

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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:

    Coma flowchart thumbnail
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