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particularly the brain and liver (see Chapter 97 Neurologic Emergencies ). An
epidemiologic association exists between the disorder and an antecedent viral
illness (including varicella) from which a patient is recovering. Patients with
Reye syndrome typically develop severe vomiting, followed by combative
delirium that progresses to coma. Cerebral edema, increased ICP, and central
herniation may occur.
Miscellaneous Conditions
Other causes of coma or ALOC in children are less easily categorized. Children
with intussusception, the most common cause of bowel obstruction in childhood,
may present with significant apathy and lethargy. As a result, they may be treated
for dehydration, sepsis, or meningitis before the appropriate diagnosis is
discovered. CNS involvement in hemolytic uremic syndrome may produce a
comatose state because of cerebral infarction, most commonly in the basal
ganglia. Breastfed infants of vegan mothers have presented in coma from severe
vitamin B12 deficiency. Children with adrenoleukodystrophy may present acutely
with coma due to CNS neuron demyelination.
Psychiatric disorders may produce a true stuporous or catatonic state. More
commonly, neurologically intact behavioral health patients may appear
unresponsive, and be remarkably successful at remaining immobile despite
painful stimuli. The nature of their illness may be discovered by a detailed
neurologic examination. Conscious patients will usually avoid hitting their face
with a dropped arm, may resist eyelid opening, will raise their heart rate to
auditory or painful stimuli, and will have intact deep tendon, oculovestibular, and
oculocephalic reflexes.

EVALUATION AND DECISION
An approach for the evaluation of pediatric patients presenting with coma is
summarized in Figure 17.1 . All patients need rapid assessment of their airway,
breathing, and circulation, followed by a focused history, physical examination
with careful neurologic evaluation, and consideration of laboratory and imaging
studies. This approach is based on the selective use of the following critical

clinical and laboratory findings: (i) Vital signs; (ii) a history of recent head
trauma, seizure activity, or ingestion; (iii) signs of increased ICP or focal
neurologic abnormality; (iv) fever; (v) laboratory results; (vi) brain CT scan
results; and (vii) CSF analysis. The evaluation of the comatose patient should
follow an orderly series of steps, addressing the more life-threatening problems of
hypoxia, hypotension, or increased ICP before investigating less urgent disorders.