5. PEDIATRIC EMERGENCIES
5.6 PEDIATRIC COMA / ALTERED MENTAL STATUS
Altered mental status in children covers a range of behaviors and can be subtle. Coma is not difficult to recognize, but irritability, lethargy, changes in feeding or sleeping habits, and other subtle behavioral changes can all indicate a process impairing the normal functioning of the child's central nervous system. History from the care giver is critical. The common causes of pediatric coma are injury, shock, metabolic disorders, ingestions and CNS infections. Pediatric shock, if suspected, should be treated according to the Pediatric Shock Protocol. Likewise, Pediatric Head Trauma, if suspected as the cause for altered mental status, should be treated according to the Pediatric Multiple Trauma Protocol. Remember that some forms of injury such as those associated with "shaken baby syndrome", can cause CNS trauma without external evidence of injury.
ASSESSMENT / TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning and/or use of airway adjuncts (nasopharyngeal airway/oropharyngeal airway) as indicated. Assume spinal injury if associated with trauma and manage accordingly.
3. Evaluate capillary refill and determine if blood pressure is appropriate for age. (SEE APPENDIX M)
4. Administer high concentration of oxygen via non-rebreather mask.
5. Determine patient's hemodynamic stability and symptoms. Continually assess level of Consciousness, ABCs and Vital Signs.
6. Obtain appropriate history related to event, including Past Medical History (diabetes, CNS disorders and/or injury), Medications, Drug Allergies and Substance Abuse (overdose) or Trauma.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain open airway and assist ventilations as needed. This may include repositioning of the a irway, suctioning and/or use of airway adjuncts (nasopharyngeal airway/oropharyngeal airway) as indicated. Assume spinal injury if associated with trauma and manage accordingly.
3. Administer high concentration of oxygen by non-rebreather mask.
4. If patient is a known diabetic who is conscious and can speak and swallow, give oral glucose or other sugar source as tolerated. CAUTION: Do NOT administer anything orally if the patient does not have a reasonable Level of Consciousness and normal gag reflex.
5. Activate ALS intercept if deemed necessary and if available.
6. Initiate transport as soon as possible with or without ALS.
7. Notify receiving hospital.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning and/or use of airway adjuncts (nasopharyngeal airway/oropharyngeal airway) as indicated. Assume spinal injury if associated with trauma and manage accordingly.
3. Administer high concentration of oxygen by non-rebreather mask.
4. If patient is a known diabetic who is conscious and can speak and swallow, give oral glucose or other sugar as tolerated. CAUTION: Do NOT administer anything orally if the patient does not have a reasonable Level of Consciousness and normal gag reflex.
5. Activate Paramedic intercept, if deemed necessary and if available.
6. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Consider IV Normal Saline (while enroute) if in severe distress.
7. Initiate Transport to appropriate facility as soon as possible with or with out Paramedics.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. 20 ml/kg Fluid bolus of Normal Saline.
9. Notify receiving hospital
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning and/or use of airway adjuncts (nasopharyngeal airway/oropharyngeal airway) as indicated. Assume spinal injury if associated with trauma and manage accordingly.
3. Administer high concentration of oxygen by non-rebreather mask (humidified Oxygen is acceptable).
4. ALS STANDING ORDERS
a. Advanced Airway Management if indicated.
b. Initiate IV Normal Saline (KVO). If a hypovolemic etiology is suspected, administer fluid bolus at 20 ml/kg.
c. Cardiac monitoring / dysrhythmia recognition. Treat per protocol. (if indicated)
d. Treatment for specific etiologies:
- Known Diabetic:
- i. Dextrose 10% 0.5 gm/kg IV Bolus (for neonates)
- ii. Dextrose 25% 0.5 gm/kg IV Bolus (if estimated body weight is less than 50 kg)
- iii. Dextrose 50% 0.5 gm/kg IV Bolus (if estimated body weight is greater than 50 kg)
- iv. Glucagon 0.1 mg/kg IV Push, IO, IM or SQ up to maximum of 1.0 mg.
- Coma of Unknown Etiology:
- i. If age less than 5 years:
- - Naloxone HCL: 0.1 mg/kg to max. dose of 2.0 mg, IV Push, ET,
- IO, IM, SQ
- - Dextrose as listed above
- ii. If age greater than 5 years:
- - Naloxone HCL: 2.0 mg IV Push, ET, IO, IM, SQ
- - Dextrose as listed above
5. Initiate transport as soon as possible.
6. Contact MEDICAL CONTROL. The following may be ordered:
a. Glucagon 0.1 mg/kg IV Push, IO, IM or SQ up to maximum of 1.0 mg.
b. 20 ml/kg Normal Saline fluid Bolus
c. Dextrose:
i. Dextrose 10% 0.5 gm/kg IV Bolus (for neonates)
ii. Dextrose 25% 0.5 gm/kg IV Bolus (if estimated body weight is less than 50 kg)
iii. Dextrose 50% 0.5 gm/kg IV Bolus (if estimated body weight is greater than 50 kg)
d. Naloxone HCL:
i. If age less than 5 years: 0.1 mg/kg to max. dose of 2.0 mg IV Bolus, ET, IM, SQ or IO.
ii. If age 5 years or greater: 2.0 mg IV Bolus, ET, IM, SQ or IO. If given via ET, follow with 2.0 ml sterile normal saline solution.
e. Additional fluid boluses of 20 ml/kg at intervals as needed.
f. If coma caused by specific drug overdose, physician may order:
i. Atropine 0.02 mg/kg IV Bolus or ET (minimum dose 0.1 mg), or IO NOTE: If given via ET, follow with 2.0 ml sterile Normal Saline solution.
ii. Sodium Bicarbonate 1-2 mEq/kg as slow IV Infusion. CAUTION: Pediatric patients must have adequate ventilatory function prior to the administration of Sodium Bicarbonate.
7. Notify receiving hospital.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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