Coma is an alteration of consciousness in which a person appears to be asleep, cannot be aroused, and shows no awareness of the environment . 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.
This topic will discuss issues related to the acute management of a child presenting with altered arousal. The differential diagnosis and evaluation of stupor and coma is presented separately. (See "Evaluation of stupor and coma in children".)
Early treatment of coma is generally supportive until a definitive diagnosis is made. An important goal of early treatment is to limit brain injury. Treatments for dangerous etiologies (eg, hypoglycemia, increased intracranial pressure, bacterial meningitis) are often initiated empirically, especially if there are suggestive clinical features.
Although discussed separately, the assessment and management of children in coma are performed jointly in practice (table 1). The primacy of ABC's (airway, breathing, circulation) applies to coma as to other medical emergencies.
Airway — Establishing a secure airway and providing adequate ventilation may be lifesaving and also may limit neurologic injury. Establishing a secure airway in a patient with coma may be attained by repositioning the child to open the airway, but often requires intubation to ensure adequate ventilation and to prevent aspiration of secretions or gastric contents. (See "Emergent endotracheal intubation in children".) Patients with GCS <8 (table 2) are usually unable to adequately protect their airway and should be intubated. If trauma is suspected, the cervical spine should be stabilized with a collar while securing the airway. Approaches to minimize the impact of intubation on potentially elevated intracranial pressure should be considered. (See "Elevated intracranial pressure (ICP) in children".)