Pediatric presentation
Altered level of consciousness in children
The drowsy child is the emergency that is easiest to miss because the child is quiet.
What are you worried about?
- Hypoglycemia
- Sepsis and meningitis or encephalitis
- Raised intracranial pressure, including non-accidental head injury
- Ingestion
- Diabetic ketoacidosis and other metabolic crises
- Non-convulsive status epilepticus
Differential, by age
Newborn birth to 28 days
- Sepsis
- Hypoglycemia
- Inborn error of metabolism
- Intracranial hemorrhage
- Hypoxic-ischemic injury
Infant 1 to 12 months
- Sepsis, meningitis
- Non-accidental head injury
- Hypoglycemia
- Intussusception (lethargy between episodes)
- Dehydration
Toddler 1 to 3 years
- Ingestion
- Meningitis or encephalitis
- Head injury
- Postictal state
- Hypoglycemia
Preschool 3 to 5 years
- Ingestion
- Diabetic ketoacidosis
- Encephalitis
- Head injury
- Intracranial mass
School age 6 to 11 years
- Diabetic ketoacidosis
- Encephalitis
- Ingestion
- Head injury
- Hyponatremia
Adolescent 12 to 17 years
- Ingestion and intoxication
- Diabetic ketoacidosis
- Meningitis
- Head injury
- Psychogenic unresponsiveness
Key history
- The tempo: sudden (bleed, seizure, ingestion) versus hours to days (infection, metabolic)
- Fever, vomiting, headache, seizure, trauma, medications and substances in the home
- Polyuria and weight loss; formula preparation in the infant; a witnessed event
- Development and the baseline; a story that changes
Key examination
- Airway, breathing, circulation, disability (including pupils and posture), exposure; glucose at the bedside
- A pediatric coma score with the age-appropriate verbal scale
- Fontanelle, head circumference, fundi, neck, rash, signs of injury
- Breath (ketones, alcohol), breathing pattern, toxidrome features
Red flags
- Any reduced consciousness with fever
- Unequal or unreactive pupils, bradycardia with hypertension, abnormal posturing
- Retinal hemorrhages, bruising, a story that does not fit
- Glucose below 2.6 mmol/L (under 3 in symptomatic older children)
- Kussmaul breathing
Initial investigations
- Bedside glucose first; then gas, electrolytes, ammonia in the infant, ketones, lactate, cultures, a toxicology screen where relevant
- Neuroimaging before a lumbar puncture when there are signs of raised pressure or focal deficits
- Lumbar puncture for suspected central nervous system infection once safe; do not delay antibiotics or aciclovir for it
How to interpret them
- Hypoglycemia with ketones in a small child is usually ketotic hypoglycemia after fasting; without ketones it is hyperinsulinism or a fatty acid oxidation defect
- A high ammonia in a drowsy infant is a metabolic emergency
- Encephalitis is a clinical diagnosis with a normal CT and often a normal early cerebrospinal fluid
When the child is deteriorating
- Protect the airway; treat glucose; treat seizures; empiric antibiotics and aciclovir when infection is possible
- Raised intracranial pressure: head up, avoid hypotension and hypoxia, hypertonic saline or mannitol, neurosurgery
- Involve intensive care early; a child whose coma score is falling is transferred before it falls further
Cases and practice
Thirsty for weeks, vomiting since this morning12 years old · A 12-year-old has been drinking litres, wetting the bed again, and losing weight. Today he cannot keep water down and is breathing strangely.He went stiff and shook, and now he will not wake up properly20 months old · A 20-month-old with a fever since the morning had a two-minute convulsion at home. His parents thought he was dying.
Conditions under this presentation
The adult frame, for contrast