Treatment and prognosis of coma in children
- Linda Thompson, MD
Linda Thompson, MD
- Cook Children's Hospital
- Houston, Texas
- Eric Williams, MD
Eric Williams, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
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 "Emergency 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".)
- Kennealy JA, McLennan JE, Loudon RG, McLaurin RL. Hyperventilation-induced cerebral hypoxia. Am Rev Respir Dis 1980; 122:407.
- Skippen P, Seear M, Poskitt K, et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med 1997; 25:1402.
- Stubgen JP, Plum F. Coma. In: Textbook of Critical Care Medicine, 5th, Fink MP, Abraham E, Vincent JL, Kochanek PM. (Eds), Elsevier Saunders, Philadelphia 2005. p.295.
- Markus HS. Cerebral perfusion and stroke. J Neurol Neurosurg Psychiatry 2004; 75:353.
- Coates BM, Vavilala MS, Mack CD, et al. Influence of definition and location of hypotension on outcome following severe pediatric traumatic brain injury. Crit Care Med 2005; 33:2645.
- Odetola FO, Bratton SL. Characteristics and immediate outcome of childhood meningitis treated in the pediatric intensive care unit. Intensive Care Med 2005; 31:92.
- Chambers IR, Kirkham FJ. What is the optimal cerebral perfusion pressure in children suffering from traumatic coma? Neurosurg Focus 2003; 15:E3.
- Williams O, Brust JC. Hypertensive Encephalopathy. Curr Treat Options Cardiovasc Med 2004; 6:209.
- Wright RR, Mathews KD. Hypertensive encephalopathy in childhood. J Child Neurol 1996; 11:193.
- Grimwood K, Nolan TM, Bond L, et al. Risk factors for adverse outcomes of bacterial meningitis. J Paediatr Child Health 1996; 32:457.
- Bhutto E, Naim M, Ehtesham M, et al. Prognostic indicators of childhood acute viral encephalitis. J Pak Med Assoc 1999; 49:311.
- Kirkham, FJ, Wairui, C, Newton, CR. Clinical and electroencephalographic seizures in coma: relationship to outcome. Arch Dis Child 2000; 82 (suppl 1):A59.
- Idro R, Carter JA, Fegan G, et al. Risk factors for persisting neurological and cognitive impairments following cerebral malaria. Arch Dis Child 2006; 91:142.
- Kramer U, Shorer Z, Ben-Zeev B, et al. Severe refractory status epilepticus owing to presumed encephalitis. J Child Neurol 2005; 20:184.
- Whitley RJ, Kimberlin DW, Roizman B. Herpes simplex viruses. Clin Infect Dis 1998; 26:541.
- Arditi M, Mason EO Jr, Bradley JS, et al. Three-year multicenter surveillance of pneumococcal meningitis in children: clinical characteristics, and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics 1998; 102:1087.
- Chesnut RM. Medical management of severe head injury: present and future. New Horiz 1995; 3:581.
- Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 17. Critical pathway for the treatment of established intracranial hypertension in pediatric traumatic brain injury. Pediatr Crit Care Med 2003; 4:S65.
- Yamamoto T, Mori K, Maeda M. Assessment of prognostic factors in severe traumatic brain injury patients treated by mild therapeutic cerebral hypothermia therapy. Neurol Res 2002; 24:789.
- Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia therapy after traumatic brain injury in children. N Engl J Med 2008; 358:2447.
- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
- Hoffman RS, Goldfrank LR. The poisoned patient with altered consciousness. Controversies in the use of a 'coma cocktail'. JAMA 1995; 274:562.
- Ashwal S. Medical aspects of the minimally conscious state in children. Brain Dev 2003; 25:535.
- Laureys S. Functional neuroimaging in the vegetative state. NeuroRehabilitation 2004; 19:335.
- 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.
- Carter BG, Butt W. A prospective study of outcome predictors after severe brain injury in children. Intensive Care Med 2005; 31:840.
- Zeman A. Consciousness. Brain 2001; 124:1263.
- Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81.
- Simpson D, Reilly P. Pediatric coma scale. Lancet 1982; 2:450.
- 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.
- Mandel R, Martinot A, Delepoulle F, et al. Prediction of outcome after hypoxic-ischemic encephalopathy: a prospective clinical and electrophysiologic study. J Pediatr 2002; 141:45.
- Jacinto SJ, Gieron-Korthals M, Ferreira JA. Predicting outcome in hypoxic-ischemic brain injury. Pediatr Clin North Am 2001; 48:647.
- Avesani R, Salvi L, Rigoli G, Gambini MG. Reintegration after severe brain injury: a retrospective study. Brain Inj 2005; 19:933.
- Ciurea AV, Coman T, Roşu L, et al. Severe brain injuries in children. Acta Neurochir Suppl 2005; 93:209.
- Bonnier C, Nassogne MC, Saint-Martin C, et al. Neuroimaging of intraparenchymal lesions predicts outcome in shaken baby syndrome. Pediatrics 2003; 112:808.
- Chiaretti A, Piastra M, Pulitanò S, et al. Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 2002; 18:129.
- Chiaretti A, De Benedictis R, Della Corte F, et al. The impact of initial management on the outcome of children with severe head injury. Childs Nerv Syst 2002; 18:54.
- Prasad MR, Ewing-Cobbs L, Swank PR, Kramer L. Predictors of outcome following traumatic brain injury in young children. Pediatr Neurosurg 2002; 36:64.
- White JR, Farukhi Z, Bull C, et al. Predictors of outcome in severely head-injured children. Crit Care Med 2001; 29:534.
- Chen R, Bolton CF, Young B. Prediction of outcome in patients with anoxic coma: a clinical and electrophysiologic study. Crit Care Med 1996; 24:672.
- Wohlrab G, Boltshauser E, Schmitt B. Neurological outcome in comatose children with bilateral loss of cortical somatosensory evoked potentials. Neuropediatrics 2001; 32:271.
- Bansal A, Singhi SC, Singhi PD, et al. Non traumatic coma. Indian J Pediatr 2005; 72:467.
- Suresh HS, Praharaj SS, Indira Devi B, et al. Prognosis in children with head injury: an analysis of 340 patients. Neurol India 2003; 51:16.
- Pfenninger J, Bachmann D, Wagner BP. Survivors with bad outcome after hypoxic-ischaemic encephalopathy: full-term neonates compare unfavourably with children. Swiss Med Wkly 2001; 131:267.
- Pressler RM, Boylan GB, Morton M, et al. Early serial EEG in hypoxic ischaemic encephalopathy. Clin Neurophysiol 2001; 112:31.
- Zandbergen EG, de Haan RJ, Stoutenbeek CP, et al. Systematic review of early prediction of poor outcome in anoxic-ischaemic coma. Lancet 1998; 352:1808.
- RamachandranNair R, Sharma R, Weiss SK, et al. A reappraisal of rhythmic coma patterns in children. Can J Neurol Sci 2005; 32:518.
- Trübel HK, Novotny E, Lister G. Outcome of coma in children. Curr Opin Pediatr 2003; 15:283.
- Carter BG, Butt W. Review of the use of somatosensory evoked potentials in the prediction of outcome after severe brain injury. Crit Care Med 2001; 29:178.
- Frank LM, Furgiuele TL, Etheridge JE Jr. Prediction of chronic vegetative state in children using evoked potentials. Neurology 1985; 35:931.
- Robinson LR, Micklesen PJ, Tirschwell DL, Lew HL. Predictive value of somatosensory evoked potentials for awakening from coma. Crit Care Med 2003; 31:960.
- Shewmon DA. Coma prognosis in children. Part I: definitional and methodological challenges. J Clin Neurophysiol 2000; 17:457.
- Mewasingh LD, Christophe C, Fonteyne C, et al. Predictive value of electrophysiology in children with hypoxic coma. Pediatr Neurol 2003; 28:178.
- Ghahreman A, Bhasin V, Chaseling R, et al. Nonaccidental head injuries in children: a Sydney experience. J Neurosurg 2005; 103:213.
- Christophe C, Fonteyne C, Ziereisen F, et al. Value of MR imaging of the brain in children with hypoxic coma. AJNR Am J Neuroradiol 2002; 23:716.
- Tong KA, Ashwal S, Holshouser BA, et al. Diffuse axonal injury in children: clinical correlation with hemorrhagic lesions. Ann Neurol 2004; 56:36.
- Kemp AM, Stoodley N, Cobley C, et al. Apnoea and brain swelling in non-accidental head injury. Arch Dis Child 2003; 88:472.
- Woischneck D, Klein S, Reissberg S, et al. Prognosis of brain stem lesion in children with head injury. Childs Nerv Syst 2003; 19:174.
- Bernat JL. Chronic disorders of consciousness. Lancet 2006; 367:1181.
- Laureys S, Owen AM, Schiff ND. Brain function in coma, vegetative state, and related disorders. Lancet Neurol 2004; 3:537.
- Nara T, Nozaki H, Nakae Y, et al. Neuron-specific enolase in comatose children. Am J Dis Child 1988; 142:173.
- Bandyopadhyay S, Hennes H, Gorelick MH, et al. Serum neuron-specific enolase as a predictor of short-term outcome in children with closed traumatic brain injury. Acad Emerg Med 2005; 12:732.
- Intracranial pressure
- Temperature control
- Acid-base and electrolyte imbalance
- Examination findings
- Other clinical features
- Evoked potentials
- Magnetic resonance imaging
- Serum biomarkers
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS