Specific Plans

1. Narcotic overdose. If suspected and patient has small pupils, administer IV naloxone to reverse opiate toxicity.

2. Head injury or focal neurologic finding. If suspected or present, or if there is a focal neurologic finding, obtain CT scan of the head and neurosurgical consultation.

3. Inflicted injury or suspected child abuse. If suspected in a child younger than 3 years of age, obtain a skeletal survey.

4. Metabolic alterations. Correct metabolic and electrolyte abnormalities and acidosis.

5. Poisoning or overdose. If suspected, administer charcoal (if ingestion occurred within 1 hour) and antidote if available.

6. Fever, CNS infection, or sepsis. Perform a lumbar puncture if patient is stable and does not have signs of increased intracranial pressure. Administer appropriate antibiotics.

7. Hyperammonemia. Consider workup for metabolic disorder.

VI. Problem Case Diagnosis. The 18-month-old patient had slow, irregular respirations and a GCS score of 8. Physical exam showed boggy swelling on the right temporal area. The cervical spine was immobilized, patient was intubated, and IV access obtained. Rapid blood glucose determination showed a glucose level of 98. Emergent CT scan of the head showed a subdural hemorrhage on the right side. Patient was admitted to the ICU with neurosurgical consultation. Subsequent evaluation revealed multiple rib fractures in different stages of healing and metaphyseal long bone fractures, all consistent with child abuse.

VII. Teaching Pearl: Question. What is the most important sign that differentiates structural from medical etiologies of coma?

VIII. Teaching Pearls: Answer. Pupillary response; it is usually preserved when coma is secondary to toxic and metabolic causes. Although pupils may be small, they are usually symmetric and reactive.

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