Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Evaluation of stupor and coma in children

David Michelson, MD
Linda Thompson, MD
Eric Williams, MD
Section Editor
Marc C Patterson, MD, FRACP
Deputy Editor
Janet L Wilterdink, MD


Coma is an alteration of consciousness in which a person appears to be asleep, cannot be aroused, and shows no awareness of the environment [1]. Coma is therefore the most profound degree to which the two components of consciousness, arousal and awareness, can be diminished. Less profound states of impaired consciousness (stupor, lethargy, obtundation) preserve one or more of these components to some degree.

Coma represents an acute, life threatening emergency, requiring prompt intervention for preservation of life and brain function. Although discussed separately, the assessment and management are performed jointly in practice (table 1).

This topic will discuss the evaluation of children presenting in stupor or coma. Initial treatment and prognosis are discussed separately. (See "Treatment and prognosis of coma in children".)


States of impaired consciousness — There is a spectrum of impaired consciousness between full arousal and complete unresponsiveness.

Coma, a state of "unarousable unresponsiveness," is the most profound degree to which arousal and consciousness are impaired [1].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Jun 26, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Plum, F, Posner, JB. The Diagnosis of Stupor and Coma III. FA Davis, Philadelphia, 1980. p.2.
  2. Zeman A. Persistent vegetative state. Lancet 1997; 350:795.
  3. Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (1). N Engl J Med 1994; 330:1499.
  4. Laureys S, Owen AM, Schiff ND. Brain function in coma, vegetative state, and related disorders. Lancet Neurol 2004; 3:537.
  5. Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975; 1:480.
  6. Levy DE, Bates D, Caronna JJ, et al. Prognosis in nontraumatic coma. Ann Intern Med 1981; 94:293.
  7. Jennett B, Plum F. Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1972; 1:734.
  8. Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (2). N Engl J Med 1994; 330:1572.
  9. Bates D. The management of medical coma. J Neurol Neurosurg Psychiatry 1993; 56:589.
  10. Andrews K, Murphy L, Munday R, Littlewood C. Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ 1996; 313:13.
  11. Ashwal S. Medical aspects of the minimally conscious state in children. Brain Dev 2003; 25:535.
  12. Moruzzi G, Magoun HW. Brain stem reticular formation and activation of the EEG. Electroencephalogr Clin Neurophysiol 1949; 1:455.
  13. Zeman A. Consciousness. Brain 2001; 124:1263.
  14. Wong CP, Forsyth RJ, Kelly TP, Eyre JA. Incidence, aetiology, and outcome of non-traumatic coma: a population based study. Arch Dis Child 2001; 84:193.
  15. Bansal A, Singhi SC, Singhi PD, et al. Non traumatic coma. Indian J Pediatr 2005; 72:467.
  16. Khodapanahandeh F, Najarkalayee NG. Etiology and outcome of non-traumatic coma in children admitted to pediatric intensive care unit. Iran J Pediatr 2009; 19:393.
  17. Fouad H, Haron M, Halawa EF, Nada M. Nontraumatic coma in a tertiary pediatric emergency department in egypt: etiology and outcome. J Child Neurol 2011; 26:136.
  18. Taylor DA. Coma in the pediatric patient: evaluation and management. Indian J Pediatr 1994; 61:13.
  19. Carty H, Pierce A. Non-accidental injury: a retrospective analysis of a large cohort. Eur Radiol 2002; 12:2919.
  20. Stubgen, JP and Plum, F. Coma. In: Textbook of Critical Care Medicine, 5th ed, Fink, MP, Abraham, E, Vincent, JL, Kochanek, PM (Eds), Elsevier Saunders, Philadelphia 2005. p.295.
  21. Markus HS. Cerebral perfusion and stroke. J Neurol Neurosurg Psychiatry 2004; 75:353.
  22. Kirkham FJ. Non-traumatic coma in children. Arch Dis Child 2001; 85:303.
  23. Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am 1999; 13:711.
  24. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81.
  25. Simpson D, Reilly P. Pediatric coma scale. Lancet 1982; 2:450.
  26. Hahn YS, Chyung C, Barthel MJ, et al. Head injuries in children under 36 months of age. Demography and outcome. Childs Nerv Syst 1988; 4:34.
  27. Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: The FOUR score. Ann Neurol 2005; 58:585.
  28. Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care 2012; 16:95.
  29. Abbruzzi G, Stork CM. Pediatric toxicologic concerns. Emerg Med Clin North Am 2002; 20:223.
  30. Tong KA, Ashwal S, Holshouser BA, et al. Hemorrhagic shearing lesions in children and adolescents with posttraumatic diffuse axonal injury: improved detection and initial results. Radiology 2003; 227:332.
  31. Sundgren PC, Reinstrup P, Romner B, et al. Value of conventional, and diffusion- and perfusion weighted MRI in the management of patients with unclear cerebral pathology, admitted to the intensive care unit. Neuroradiology 2002; 44:674.
  32. Ghahreman A, Bhasin V, Chaseling R, et al. Nonaccidental head injuries in children: a Sydney experience. J Neurosurg 2005; 103:213.
  33. Tong KA, Ashwal S, Holshouser BA, et al. Diffuse axonal injury in children: clinical correlation with hemorrhagic lesions. Ann Neurol 2004; 56:36.
  34. Sébire G, Tabarki B, Saunders DE, et al. Cerebral venous sinus thrombosis in children: risk factors, presentation, diagnosis and outcome. Brain 2005; 128:477.
  35. Figg RE, Burry TS, Vander Kolk WE. Clinical efficacy of serial computed tomographic scanning in severe closed head injury patients. J Trauma 2003; 55:1061.
  36. Kaups KL, Davis JW, Parks SN. Routinely repeated computed tomography after blunt head trauma: does it benefit patients? J Trauma 2004; 56:475.
  37. Talan DA, Hoffman JR, Yoshikawa TT, Overturf GD. Role of empiric parenteral antibiotics prior to lumbar puncture in suspected bacterial meningitis: state of the art. Rev Infect Dis 1988; 10:365.
  38. Markand ON. Pearls, perils, and pitfalls in the use of the electroencephalogram. Semin Neurol 2003; 23:7.
  39. Young GB. The EEG in coma. J Clin Neurophysiol 2000; 17:473.
  40. Mewasingh LD, Christophe C, Fonteyne C, et al. Predictive value of electrophysiology in children with hypoxic coma. Pediatr Neurol 2003; 28:178.
  41. Brenner RP. Is it status? Epilepsia 2002; 43 Suppl 3:103.
  42. Yemisci M, Gurer G, Saygi S, Ciger A. Generalised periodic epileptiform discharges: clinical features, neuroradiological evaluation and prognosis in 37 adult patients. Seizure 2003; 12:465.