Emergent evaluation and management of stupor and coma in children

• Vital signs and general and trauma examination
• Neurologic examination and GCS
• Fingerstick blood glucose
• Blood gas (arterial or venous)
• Screening laboratories (CBC, glucose, electrolytes, BUN, creatinine, blood and urine cultures, LFTs, urinalysis, urine drug screen)
• Head CT scan: do urgently if focal neurologic signs, papilledema, or fever; consider rapid MRI instead if available
• Lumbar puncture: do urgently after CT scan if fever, elevated WBC, meningismus; otherwise, do according to level of suspicion for diagnosis or if cause remains obscure
• Other laboratory tests: for metabolic conditions^*, coagulation tests, carboxyhemoglobin, specific drug concentrations; do according to level of suspicion for diagnosis or if cause remains obscure
• EEG: for possible nonconvulsive seizure, or if diagnosis remains obscure
• Brain MRI with DWI, if cause remains obscure

• Intubate if GCS ≤8 or respiratory failure
• Stabilize cervical spine
• Supplement O₂
• IV access
• Blood pressure support as needed

• Ceftriaxone 100 mg/kg (maximum single dose 2 grams) and vancomycin (age-specific dose)
• Acyclovir (age-specific dose)

• Naloxone 0.1 mg/kg IV in patients up to 20 kg or ≤5 years; maximum 2 mg IV (use if opioid toxidrome: miosis, respiratory depression, hypotonia)

• Mannitol 0.5 to 1 g/kg IV;
• or
• Hypertonic saline 3% 5 mL/kg

Also, elevate head and keep midline

• Lorazepam (0.1 mg/kg, maximum single dose 4 mg). If suspicion of seizures continues, treat as for status epilepticus.
• Fosphenytoin (10 to 20 PE equivalents/kg). If suspicion of seizures continues, treat as for status epilepticus.