A CHILD IN A COMA

Differential diagnosis of coma in children

• Hypoxic-ischaemic brain injury, e.g. following a respiratory arrest

• Epileptic seizure/postictal state

• Trauma, e.g. intracranial haemorrhage, cerebral oedema

• Infections, e.g. meningitis, encephalitis, abscess

• Metabolic – renal and hepatic failure, hypoglycaemia, diabetic ketoacidosis, inborn errors

• Poisoning

• Vascular lesions, e.g. stroke

The AVPU score is a score used for the rapid assessment of the conscious level of a child (especially 5 years of age). A Alert, V responds to Voice, P responds only to Pain, U Unresponsive to all stimuli. P or less corresponds to a GCS of 8 or less. The CT shows an acute subdural haemorrhage over the right hemisphere. The most likely mechanism is a shaking injury (the ‘shaken baby syndrome’) or possibly a direct impact. The pulse is raised and the capillary refill time is prolonged. This would fit in with an intracranial bleed and vomiting (note the haemoglobin is low and the lactate and base excess are raised due to poor perfusion). A bolus of 20 mL/kg of 0.9 per cent saline should therefore be administered. In any child with an AVPU score of P or U, the airway is at risk and an anaesthetist should therefore be called. A broad-spectrum antibiotic, e.g. cefotaxime, should be given as soon as possible to cover the possibility of sepsis. The bulging anterior fontanelle indicates raised intracranial pressure. In infants, unfused sutures and a patent anterior fontanelle allow the cranial volume to increase. Raised intracranial pressure is therefore better tolerated in its initial stages and large bleeds may occur before neurological features develop. Management of raised intracranial pressure includes sitting the infant at a 30º angle, restricting fluids to two-thirds maintenance, and elective intubation and ventilation to maintain the PCO2 at 4–4.5 kPa (intubation will also secure the airway and help ensure a safe transfer). The child should also be well oxygenated and normoglycaemic. An urgent discussion needs to be held with the regional neurosurgical centre to discuss whether the infant should be administered mannitol or hypertonic saline to help decrease the intracranial pressure. Arrangements will need to be made for an urgent neurosurgical assessment to determine whether surgery is required to evacuate the haematoma. This injury is most likely to have been intentional. Social services should therefore be contacted and child protection procedures followed.

KEY POINTS

• Urgent transfer of acutely ill children with an intracranial bleed to a neurosurgical unit is mandatory, as a haematoma may need to be surgically evacuated.

• The majority of serious intracranial injuries in the first year of life are the result of non-accidental injury.