Scales for coma have been created as a means to help better predict the outcome of the patient and the depth of consciousness. The use of various neurophysiologic tests and clinical tests help determine the potential outcome. However, the scales that have been developed are used for people of all ages, and this presents a problem when dealing with children.
Difficulties of Using Traditional Coma Scale in Children
The Glasgow Coma Scale can be difficult to apply to pediatric patients. This is especially true when it comes to the verbal scale. Naturally, this would not work with young children. Additionally, there are difficulties with determining motor response in children. Small children, particularly those who are nine months and younger, “can’t consistently localize pain stimulus” for example. Children who are 18 months and younger can’t obey commands reliably since their language is not developed enough at that point.
However, there is a modified GCS that could be used, and that can better assess coma in children, including those who are quite young. It has motor and verbal scales that are better suited to the younger ages, which can provide clinicians with a better overall assessment.
The modified scale uses withdrawal to touch and pain and normal spontaneous movements as indicators. This tends to make the score easier to interpret and to discuss with others when talking about the patient’s condition.
The use of clinical neurophysiology, particularly in the pediatric intensive care unit, is to ensure that there are a proper diagnosis and prognosis of the children. Naturally, there needs to be differences when it comes to working with children than when working with adults. This includes “clinical indications, immaturity (yielding different norms and different pathophysiological processes), and technical limitations”.
Monitoring is used for two main reasons. First, there is the overall prognosis of the child. The second is for seizure detection. By detecting seizures, it can often help to provide a more accurate prognosis. It’s believed that some patterns will hold a poor prognosis for the children.
These troubling patterns include “electrocerebral silence in the EEG; a burst–suppression pattern in children older than 32 weeks of conceptional age; and a brainstem auditory evoked potential, suggesting a pontine lesion in children older than 35 weeks of conceptional age”.
With the right tools, personnel, and equipment, it is often possible to detect seizures early. There was a study that found that using amplitude-integrated EEG in infants with encephalopathy could detect 55% of seizures, and this was higher in seizures that lasted for longer.
To get a better sense of the seizure activity happening with the pediatric coma patients, facilities will need to be sure they have personnel trained to detect them visually. Many facilities are trying to utilize continuous EEG monitoring, although this will require better data storage and the ability to properly monitor these patients. However, it has the potential to provide doctors with a much better idea of what’s happening with their patients.
Again, when monitoring children in a coma, just like when trying to assess them, it’s important to think of them as children rather than small adults. This means that certain procedures and monitoring equipment may need to be adapted. For some facilities, this will mean added expenses, but it could be well worth the cost.
A Better Understanding
When implementing the right types of assessments and tools, doctors may be able to provide a more accurate prognosis for the comatose children under their care. This requires proper training, the right equipment, and a willingness to reassess how things are done in the clinic to better accommodate children.