Emergency and intensive care management of a comatose patient with intracranial hypertension, current concepts.

ABSTRACT

Altered mental status is a common occurrence in children with acute critical illness. The causes of non-traumatic coma are diverse ranging from neurological to systemic causes. Early appropriate supportive care is essential to avoid preventable secondary insults and optimize the neurological outcome. Evaluation and stabilization of the patient's airway, breathing and circulation (ABCs) must proceed simultaneously with assessments of the depth of coma and the presence of raised intracranial pressure (ICP). Any rapidly correctable cause of coma must be immediately corrected. Most patients with non-traumatic encephalopathies have raised ICP, although papilledema may be absent and the CT scan may be normal if ICP elevation occurs acutely. The most important early treatment for raised ICP is controlled intubation and ventilation followed by osmotherapy. Early control of seizures, including non-convulsive seizures is important. Urgent imaging is indicated in most cases particularly in the presence of afebrile coma, focal signs or papilledema. Following stabilization, isotonic fluids are administered, aiming for euvolemia and euglycaemia. Ventilation should aim for the lower end of eucapnia to avoid causing cerebral ischemia. Surgical options should be explored and, in refractory intracranial hypertension, barbiturates and mild hypothermia may have a role.