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Sensorium in Children

Dr. Gurdev Chowdhary, et. al

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Clinical Evaluation

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:

  1. To determine the cause of coma.
  2. To delineate the area of the brain which is involved.
  3. To determine further course of management which will result in reversing the process and enhance the chances of recovery.


The history must be directed at the following:

  1. Mode of onset of illness.
  2. Presence or absence of preceding warning symptoms.
  3. Temporal course of illness.
  4. Treatment given and the response to the treatment.

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.

Table No. 1 – Mode of onset


  • Trauma
  • Cerebro-vascular accidents
  • Seizures


  • Infections,
  • Metabolic derangements
  • Poisonings
  • Physical agents,
  • Heat stroke,
  • Hypothermia


  • Neoplasms
  • Degenerative diseases
  • Slow virus diseases

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


  • Infections
  • Neoplasms
  • Degenerative diseases
  • Metabolic derangements
  • Hepatic, renal encephalopathy
  • Epilepsy


  • Trauma
  • Accidental poisoning
  • Cerebro-vasular accident
  • Rapidly expanding mass lesions

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:

  • Hypothyroidism
  • Hypopituitarism
  • Congenital errors of metabolism

Pallor is seen in

  • Acute blood loss; trauma, intra-cranial haemorrhage
  • Shock (septicemic or hypovolaemic)

Chronic renal failure

Jaundice – Hepatic encephalopathy

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