Drowsiness or decreased level of consciousness post-election crisis

Specialty: Pediatrics.

• Post-critical state
• postictal drowsiness
• postconvulsive stupor

Why it occurs

• Transient cortical depression post-epileptic seizure or postictal phase (neuronal metabolic exhaustion, increase in inhibitory neurotransmitters such as GABA and accumulation of adenosine after a massive synchronous neuronal discharge)
• Acute herpetic/bacterial meningitis or encephalitis (active infection of the brain parenchyma or meninges that perpetuates drowsiness after a febrile or afebrile seizure)
• Accidental drug or toxic intoxication (ingestion of benzodiazepines, first generation antihistamines, anticonvulsants or opiates that induce pharmacological coma)
• Acute cerebral edema or intracranial hypertension (consequence of head trauma, prolonged status epilepticus or severe electrolyte disorders such as hyponatremia)
• Acute intracranial hemorrhage (rupture of arteriovenous malformation or traumatic bleeding that associates neurological focality and deterioration of consciousness)

Initial workup

Immediate determination of capillary blood glucose (ruling out post-critical hypoglycemia) and continuous pulse oximetry. Urgent analysis that includes blood gas (to assess lactic or respiratory acidosis), complete ionogram (sodium, potassium, chloride, ionic calcium, ruling out dilutional hyponatremia), complete blood count, CRP, procalcitonin, serum levels of anticonvulsant drugs (if the patient was under treatment) and urine toxicological screening. Urgent computed tomography (CT) of the head if a mass, hemorrhage or trauma is suspected. Lumbar puncture for CSF analysis once severe intracranial hypertension has been ruled out by CT or fundus examination. Urgent electroencephalogram (EEG) if non-convulsive status epilepticus is suspected (persistent drowsiness due to continuous subclinical seizures).

Standard management

• Initial management focuses on ensuring airway, ventilation and perfusion — ABCDE protocol). High concentration supplemental oxygen. 0.9% Physiological Serum (in boluses of 20 ml/kg IV if there are signs of shock). If intracranial hypertension is confirmed: Mannitol 20% (dose of 0.25 to 1 g/kg IV to be administered over 20 minutes) or Hypertonic saline 3% (dose of 3 to 5 ml/kg IV in slow infusion
• Intravenous acyclovir — urgent empirical initiation if herpes encephalitis is suspected; dose of 60 mg/kg/day divided every 8 hours IV in children under 12 years of age
• Ceftriaxone plus Ampicillin (empirical coverage of bacterial meningitis; ceftriaxone dose of 100 mg/kg/day IV).