Drowsiness and impaired consciousness in children

April 16, 2018 00:15 | Diagnostics
There are three degrees of depth of consciousness disturbance:

1. Drowsiness : the child is in a drowsy-sleepy state, not interested in others, but reacts to immediate stimuli and answers questions. There can also be phases with a clear consciousness. The extreme degree of drowsiness is called lethargy.

2. : The impairment of consciousness, which can only be overcome for a short time by strong irritants. The child can not chew food and keeps it in his mouth.

3. Coma : Deep loss of consciousness that can not be overcome, even by strong stimuli. Reflexes of cutaneous, mucous membranes, tendon, and pharyngeal are not caused. The child urinates and defecates under himself.

The causes may be:

Poisonings of .

Metabolic disorders :
- diabetes mellitus;
- hypoglycaemia;
- uremia;
- dehydration;
- diabetes insipidus;
- a violation of the liver.

Endotoxic shock .

Cerebral disorders of consciousness :
- convulsive status;
- the status of small epilepsy;
- increased intracranial pressure;

- fainting;
is a psychogenic twilight state.


In all cases of impaired consciousness in a child, it is first of all necessary to exclude poisoning. Only then must think about other possible causes. In a healthy child, a violation of consciousness can be caused by a lack of sleep or a hysterical reaction. If there is no possibility to carry out laboratory investigations immediately, assuming poisoning, the doctor is forced to rely solely on the history data and proceed from the theoretical probability of poisoning with one substance or another in accordance with the child's age. An acute onset against a background of complete health, rapidly developing psychomotor and sometimes gastrointestinal disturbances are very typical for poisoning. Specific age risk factors should be considered:

1. In the first year of life( less often later in life), an overdose of medication by a child is too troublesome or insufficiently informed by parents in the hope of a faster effect( antipyretic, sedative, antitussive drugs).

2. At the age of 2-4 years, self-administration of medicines or household chemicals while keeping these funds in an accessible place;sometimes they can be given by older brothers and sisters.

3. Beginning with school age, deliberate use of medicines. Sometimes during the game the child uses berries and fruits for food, not knowing about their toxicity.

4. In prepubertal and puberty age: drug abuse, inhalation of organic solvents( toluene, gasoline, etc.);attempts to commit suicide, most often with the help of hypnotics.

It is often difficult to collect an anamnesis giving knowingly incorrect information for fear of possible legal liability. For this reason, they deny even an accidental overdose and the possibility of the child taking carelessly stored medicines. The child often denies taking medication out of a sense of solidarity or shame. Attempts to commit suicide, on the contrary, are often undertaken demonstratively, in such cases empty packets of medicines or farewell letters are left in a prominent place. However, relatives sometimes hide it, so you have to completely focus on the symptoms of poisoning:

Alcohol : the smell of exhaled air.

Barbiturates : deep unconsciousness, up to coma, mild cyanosis, open mouth, absence of tendon and corneal reflexes, very narrowed or, conversely, dilated pupils, muscle and arterial progressive respiratory failure, local disorders of blood supply to the skin( bedsores).

Tranquilizers : loss of consciousness right up to coma. With medications of a number of phenothiazine, dystonic reactions of voluntary muscles, sometimes rigidity of the occipital muscles, spastic, torticollis, trismus, opisthotonus.

Salicyylate poisoning : lethargy, coma, frequent vomiting, hyperventilation, respiratory alkalosis, severe dehydration.

In all cases, if a child is suspected of being poisoned, it is urgent to be hospitalized, so that when the toxic effects that can not be predicted can be anticipated, maintain vital functions until a final diagnosis is made. Urine and vomit need to keep
for analysis!

Metabolic disorders

Diabetes mellitus.1. Ketoacidotic coma ( the most common form).Deep rapid breathing( Kussmaul), strong odor of acetone from the mouth, slight hyperemia of the facial skin, dry skin, severe dehydration, soft eyeballs, frequent soft pulse, decrease or absence of tendon reflexes.

Thorough examination and laboratory data only complement the clinical picture and serve to differentiate the forms of diabetes.

2. Hyperosmolar non-acidic coma ( especially at the first manifestation in the detoy): azotemia absent or mild, pronounced dehydration, very high blood sugar( more than 1000 mg%), hypernatremia, urea gradually increases in blood( azotemia).As a result, the osmolarity of the extracellular fluid rises so much that it leads to osmotic diuresis, a significant loss of intracellular fluid. High blood sugar also increases the osmotic gradient( the ratio of sugar concentration in the blood to the sugar content in the cerebrospinal fluid).In connection with the relative decrease in osmotic pressure of the cerebrospinal fluid, the level of sodium sharply increases, which ultimately leads to edema of the brain. With hyperosmolar coma, stupor, coma and convulsions quickly occur.

3. Hypoglycemic coma : normal breathing, severe pallor of the face, moist skin, especially on the hands and feet, which are mostly cold. The pulse is slow, hard, sometimes irregular, the eyeballs are usually tight, the tendon reflexes are kept, sometimes animated. In children hypoglycemia can be associated with an overdose of insulin or an inborn violation of carbohydrate metabolism, and during periods of rapid growth there are also episodes of morning hypoglycemia due to a prolonged( throughout the night) lack of food intake. Since morning episodes usually occur at a time when a child gets out of bed, they are often mistaken for orthostatic syncopal seizures. However, unlike the latter, hypoglycemic fainting can be prevented if a child 10 minutes before getting out of bed drinks a glass of 5% glucose solution. In other forms of childhood hypoglycemia, loss of consciousness is not a leading symptom.

Uremia .At a coma of a renal origin in the anamnesis there is enough enough instructions on a renal pathology underlying a disturbance. However, the growing thirst, pollakiuria and nocturia in children are considered as age features. The doctor sometimes does not notice a small swelling of the pale face and a poorly pronounced edema in the lower third of the tibia, so that the symptoms of uremia seem unexpected to him. Then, however, the air exhaled by the child and his body acquire a characteristic smell of urine, breathing deepens( compensatory hyperventilation with metabolic acidosis).Pupils are narrowed, reflexes are raised up to convulsive readiness. In many cases, high blood pressure is determined against a background of unconsciousness, which in itself can be regarded as an indication of the nephrogenic etiology of a coma before urine analysis or the detection of elevated levels of urea, uric acid and creatinine in the serum confirm the diagnosis.

The laboratory data are very important for the duration of the diagnosis of hypochloremic nitrogen coma, which, in children with diseased kidneys, against a background of a very strict salt-free diet is especially easy to develop as a result of severe vomiting without salt compensation or as a result of an uncorrectable fluid infusion and can phenotypically replicate renal dysfunction. Deficiency of sodium chloride can be masked by strong dehydration with high hematocrit. Rehydration and the introduction of table salt in these cases quickly normalize the content of urea and restore consciousness.

Dehydration of .Dehydration itself can be a cause of loss of consciousness in young children. In such cases, however, one should not forget about the possibility of unrecognized diabetes insipidus, in which insufficient inflow of fluid in young children, especially quickly leads to hyperosmolarity and development of coma.

Dysfunction of the liver .Hepatogenicity of impaired consciousness based on clinical symptoms alone is difficult to diagnose. The task is facilitated if the coma develops against a background of liver disease or in the presence of jaundice, as well as unpleasant liver odor( raw liver) from the mouth;enlarged, hard and painful palpation of the liver, signs of ascites, palpable spleen, forced breathing and bleeding. Patients with chronic liver disease are characterized by palmar erythema, "vascular sprouts" on the skin, sometimes reddish exanthema of the face and upper body, a tendency to arterial hypotension and tachycardia.

Diagnosis : the content of transaminases, bilirubin and ammonium in the blood is increased, cholesterol and its ethers - reduced.

Endotoxic shock .In the initial phase of an infectious disease, loss of consciousness may be a symptom of septic shock, especially if the pathogen is Gram-negative bacteria. Emerging soon signs of sepsis facilitate the diagnosis.

Cerebral disorders of consciousness

Among cerebral causes of growing or acute impairment of consciousness, epilepsy with a postconvulsive phase and epileptic status are the first in frequency in children.

Condition after epileptic seizure of .If we do not have the appropriate history, then post-convulsive state is indicated by: irregular myoclonic twitching, transient suppression of reflexes and post-hypnotic sleep, which can be interrupted by vomiting;In a short time after a fit, there may be a subfebrile temperature. The diagnosis is confirmed if a twilight state develops with strong excitation, emotional discharge and aggression.

The epileptic status of .If loss of consciousness is accompanied by a series of large seizures, diagnosis is not difficult. At the same time, the epileptic twilight state as the equivalent of the status is diagnosed mainly by EEG;The diagnosis is facilitated if the twilight consciousness ends with detailed convulsions. The following data facilitate the diagnosis: bilateral synchronous myoclonias, nods or episodes of a sudden sharp decrease in muscle tone. Similar symptoms on the background of impaired consciousness may be the first sign of increased intracranial pressure.

Diagnosis of : the slightest suspicion of cerebral genesis of impaired consciousness shows an electroencephalographic study.

Syncope .The unconscious state does not last long and is usually not accompanied by cramps. Fainting is often provoked by affect, coughing, constriction, impaired blood circulation regulation associated with rapid growth or heart disease. It should be determined whether the patient has paroxysmal tachycardia.

Psychogenic Twilight State .In each case of prolonged impairment of consciousness, especially in prepubescent girls, one should think about the possibility of psychogenic disorders of consciousness, against which usually there is a hysterical fit with a perfectly normal ECG.Such a genesis of a fit and twilight state is indicated by the psychopathic structure of the personality, normal reflexes during the attack( pupillary reaction to light!), And demonstrative behavior.
Women's magazine www. BlackPantera.en: G. Everbeck