What is the management of unconsciousness in pediatric patients?

Management of Unconsciousness in Pediatric Patients

Immediately secure the airway, provide high-flow oxygen, check blood glucose, establish vascular access, and assess the level of consciousness using the AVPU scale or pediatric Glasgow Coma Scale—children with a score ≤8 require elective intubation and ventilation. 1

Initial Assessment and Stabilization (ABCDE Approach)

Airway and Breathing

• Open the airway using head tilt-chin lift or jaw thrust maneuver in unconscious children 1
• Administer high-flow oxygen (15 L/min) immediately via face mask or bag-valve-mask ventilation 1
• Electively intubate and ventilate any child with Glasgow Coma Score ≤8 or inability to localize pain 1, 2
• Maintain airway patency continuously—unconscious children lose protective airway reflexes and are at high risk for obstruction 1
• Use bag-valve-mask ventilation (500 mL or 1600 mL self-inflating bag) if spontaneous ventilation is inadequate 1

Circulation

• Establish vascular or intraosseous access immediately 1
• Assess for shock: check capillary refill, pulse quality, blood pressure, and urine output 1
• In children with coma and shock, use human albumin solution as the resuscitation fluid of choice (associated with 5% mortality vs 46% with saline in this specific subgroup) 1
• Administer fluids cautiously—stop once signs of circulatory failure reverse 1
• Monitor urine output (target >1 mL/kg/hour) as a guide to adequate perfusion 1
• If shock persists despite 40 mL/kg fluid, proceed with elective intubation, ventilation, and central venous catheter placement 1

Disability: Neurological Assessment

• Rapidly assess consciousness level using AVPU scale (Alert, Voice, Pain, Unresponsive) or pediatric Glasgow Coma Scale 1
• Check pupillary size and reaction to light 1
• Observe for posturing, convulsive movements, and abnormal neurological signs 1
• Immediately check blood glucose—hypoglycemia (<3 mmol/L or <54 mg/dL) can precipitate coma and must be corrected urgently 1

Positioning and Monitoring

Recovery Position

• For children with decreased responsiveness who do not require immediate resuscitation, place in the recovery position 1
• Continue monitoring for signs of airway occlusion, inadequate or agonal breathing, and worsening unresponsiveness 1
• Reposition supine immediately if the recovery position impairs your ability to assess signs of life 1
• Never leave prone or face-down—reposition supine for reassessment due to aspiration and positional asphyxia risk 1

Continuous Monitoring Requirements

• Pulse oximetry and heart rate monitoring continuously 1
• Respiratory rate and blood pressure intermittently (at minimum every 5 minutes for deeply unconscious patients) 1
• Document vital signs in a time-based record 1
• Use precordial stethoscope or capnography when the child is difficult to observe 1

Management of Specific Scenarios

Coma with Suspected Raised Intracranial Pressure

• Position with head elevated 20-30° to improve venous drainage 2
• Maintain adequate cerebral perfusion pressure (CPP) ≥60 mmHg 2
• Administer mannitol 0.5-1 g/kg IV over 5-10 minutes for osmotic diuresis 2
• Maintain normal PCO₂ levels—avoid hyperventilation unless signs of impending herniation 1, 2
• Critical caveat: In children with pre-existing metabolic acidosis who are self-ventilating to very low PCO₂, avoid rapid normalization during intubation as this can precipitate dangerous ICP spikes 1, 2

Seizure Management in Unconscious Children

• Administer lorazepam 0.1 mg/kg IV/IO as first-line treatment 1, 2
• Repeat lorazepam 0.1 mg/kg if seizures persist after 10 minutes 1
• If seizures continue, give paraldehyde 0.4 mg/kg rectally 1
• Do not use prophylactic anticonvulsants—they may increase mortality 2
• Delay intubation decision if child is postictal with patent airway and adequate respiration 1

Equipment and Personnel Requirements (SOAPME Protocol)

Ensure immediate availability of: 1

• S (Suction): Size-appropriate suction catheters and functioning Yankauer suction
• O (Oxygen): Adequate oxygen supply with functioning flow meters (15 L/min capacity)
• A (Airway): Size-appropriate nasopharyngeal/oropharyngeal airways, laryngoscope blades (straight blade for infants/young children, curved for older children), endotracheal tubes, stylets, face masks, bag-valve-mask
• P (Pharmacy): Emergency drugs including glucose, lorazepam, mannitol, epinephrine, and reversal agents (naloxone, flumazenil)
• M (Monitors): Pulse oximeter, blood pressure cuff, ECG monitor, capnography
• E (Equipment): Defibrillator readily available

Personnel Competency

• At minimum, one person trained in pediatric advanced life support must be present 1
• The practitioner must be skilled in bag-valve-mask ventilation and advanced pediatric airway management 1
• A dedicated observer must continuously monitor vital signs and be prepared to assist with resuscitation 1

Critical Differential Diagnoses to Consider

• Hypoglycemia: Check immediately—most rapidly reversible cause 1
• Severe malaria (in endemic areas or travelers): Look for fever, convulsions, retinopathy with patchy retinal whitening and hemorrhages 1
• Meningitis/encephalitis: Assess for neck stiffness, full fontanel in infants 1
• Poisoning/toxicity: Consider in any unexplained unconsciousness, especially with high anion gap metabolic acidosis 3
• Intracranial hemorrhage: Evaluate for trauma history 1
• Metabolic disorders: Check electrolytes, acid-base status 3, 4

Common Pitfalls to Avoid

• Delaying intubation in children with GCS ≤8—these patients cannot protect their airway 1, 2
• Aggressive hyperventilation in ventilated patients—maintain normal PCO₂ unless herniation is imminent 1, 2
• Rapid PCO₂ normalization during intubation of children with compensatory hyperventilation from metabolic acidosis 1
• Excessive fluid resuscitation in comatose children—use albumin preferentially and stop once shock resolves 1
• Assuming recovery position is safe without monitoring—airway obstruction can develop rapidly 1
• Using saline instead of albumin for resuscitation in children with both coma and shock 1