Specific Issues

Airway issues of importance in the comatose patient include concerns for cervical spine injury and increased intracranial pressure. If trauma is suspected, stabilization of the cervical spine during the diagnostic process must be maintained. Issues of intubation in the head-injured patient, or in a comatose patient with suspected increased intracranial pressure who needs modification of rapid sequence intubation techniques, are discussed at length in Chap 15 and Chap 247.

In the pediatric patient, causes of coma differ from the adult. Toxic ingestions, infections, and child abuse all assume a greater frequency.

Nonconvulsive status epilepticus, or subtle status epilepticus, is an area of increasing interest. Patients who have had generalized seizures and remain unresponsive may have a prolonged postictal state or be in a continuing state of electrical seizures without corresponding motor movements. This has been termed electromechanical dissociation of the brain and body. If the motor activity of the seizure has been stopped and the patient's level of consciousness has not lightened within 30 min, the existence of this subtle status epilepticus should be considered and urgent EEG or neurologic consultation sought.

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