A systematic approach to the initial evaluation of the child with altered sensorium may mean the difference between survival or death and permanent neurologic sequelae or full recovery.
A functional airway, adequate ventilation, effective cardiac output and perfusion pressure must be ensured before any attempt to reach at the diagnosis is made. A thorough, yet gentle examination for signs of internal or external haemorrhage must be performed.
Assessment consists of taking a directed history, general physical examination, neurological examination, neuro-imaging, EEG and determination of chemical, cytologic and microbiologic content of the various body fluids.
The specific objectives aimed for assessment of a patient with altered sensorium are:
The history must be directed at the following:
In addition, factors like age of the child may have a bearing on the cause of altered sensorium e.g. inborn-errors of metabolism present during neonatal period or early infancy. Pyogenic meningitis is more common below 3 years of age, whereas, viral encephalitis usually occurs after the age of 6 years. Cardio-vascular accidents take place more commonly in older children as compared to infants.
The clinician must be aware of the racial, geographic and seasonal variations in causes of coma e.g. polio encephalitis is more common during the monsoons whereas, ARBO viral encephalitides and cerebral malaria epidemics fall usually in summers. Mode of onset : The onset of illness may be acute, subacute or insidious depending on the cause.
Preceding warning symptoms: Altered sensorium may or may not be preceded by warning symptoms like fever, headache, jaundice, seizures, vomiting, anuria, polyuria/polydipsia, diarrhoea and exposure to heat/cold depending upon the cause.
Table No. 2 – Preceding Warning symptoms
General Physical Examination
A general physical examination, systematically conducted gives vital clues that might finally lead to the diagnosis.
Characteristic facies: if any, point to the following conditions:
Pallor is seen in
Jaundice – Hepatic encephalopathy