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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Round one
1. Definition
Statement 1a
Children presenting to hospital are recognised as having a
reduced conscious level if they score less than 15 on the modified
|
%
Agree |
%
Disagree |
Result |
|
89.0% |
2.7 % |
Included |
|
Position |
Comments |
|
ED |
Needs to be discussed in context of the components of the GCS eg EO 3, BVR 5, BMR 6 = 14 may be less concern than EO 4, BVR 4, BMR 6 = 14 |
|
ED P |
Pretty much the definition, but GCS of 14 if there is impairment of motor score is more significant than if there is loss of one point on verbal or eye opening |
|
Paed |
I feel we should stick to this strict definition, rather than debate the niceties of what score would constitute a significant reduction in conscious level |
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Metab |
As the observations are not exact and somewhat subjective
15 is an unrealistic cut-off |
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Neuro |
This is too high a threshold (will include too many
children) with relatively minor degrees of disorientation/non-cooperation
that may be due to inter-observer error and discredit the guidelines. Motor
responses most useful, and this crucially requires reliable advice on how to
distinguish withdrawal from localisation |
|
PICU |
A confusing question. It depends on the case definition of “reduced conscious level”. It is accurate to say that anyone with a GCS below 15 has an altered level of consciousness. The GCS in this case is merely the measuring tool being used to define that state. For example, you have a reduced conscious level when you are asleep – we use a different behavioural scale to define that state. I note that in the title of the algorithm you use “altered consciousness”. Why not rephrase the question and see if you get consensus on: In acute care an altered level of consciousness is defined as a Glasgow Coma Scale score of 14 or below |
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Metab |
Personally I dislike using a score, but prefer a description of the child’s function, albeit set out in the same way. I think, esp considering the appearance of ill children without a neurological illness that under 15 is too inclusive, and would suggest under 13, if a score is to be used |
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Neuro |
Useful basic “quick and dirty” assessment |
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Metab |
Assuming no drugs/medications being used – ie spontaneously developed |
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Neuro S |
In principle yes this is true, but I’ve always found the “modified verbal” sections much less objective than in adults. Clinically I think the motor response is the most robust and objective measure of conscious level and would be more concerned about M<6 than GCS <15 |
|
Endo |
Although if 14 due to only 3 on best eve response, it may not be especially worrying |
|
Paed |
Children can easily score 14 (sleep) without having a decreased level of consciousness, In practice less than 14 “reduced conscious level” |
Statement 1b
Children presenting to hospital are recognised as having a reduced conscious level if they are responsive to voice, pain or are unresponsive on the AVPU scale.
|
%
Agree |
%
Disagree |
Result |
|
76.7 % |
10.0% |
Included |
|
Position |
Comments |
|
Neuro |
Little personal experience of AVPU and no idea how good it’s interrater reliability is: we’d be going against a lot of other existing work if we endorsed its use in preference to GCS, and its lack of a specific motor scale is concerning |
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Renal |
Should the statement read: “only responsive to voice, pain….” |
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Neuro |
don’t understand the statement. AVPU scale can be helpful |
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Metab |
This question does not make sense to me |
|
ED P |
I think this should be worded as “esponds only to voice, pain or are …” They could be asleep and be V. I would take P or below as reduced conscious level |
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PICU |
A confusing question. It depends on the case definition of “reduced conscious level”. It is accurate to say that anyone with a GCS below 15 has an altered level of consciousness. The GCS in this case is merely the measuring tool being used to define that state. For example, you have a reduced conscious level when you are asleep – we use a different behavioural scale to define that state. I note that in the title of the algorithm you use “altered consciousness”. Why not rephrase the question and see if you get consensus on: In acute care an altered level of consciousness is defined as a Glasgow Coma Scale score of 14 or below. Same comment as above - we need to agree on case definition for altered consciousness |
|
ED |
AVPU is less useful and gives less information as well as taking almost as long to do |
|
Metab |
I’m not familiar with AVPU scale or its use |
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Paed |
I feel we should stick to this strict definition, rather than debate the niceties of what score would constitute a significant reduction in conscious level |
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PICU N |
However, do need to take into consideration time of day/night and norm for child |
|
Metab |
V - Assumes normal hearing, etc |
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Paed |
Again common sense applies re: time of night |
|
PICU |
If U – will lead to action without further assessment. If V or P further assess with GCS likely |
Statement 1c
For assessing changes in conscious level, the modified
|
%
Agree |
%
Disagree |
Result |
|
81.8% |
0 % |
Included |
|
Position |
Comments |
|
Neuro |
rough measure…but no better scales available |
|
ED P |
Yes for more precise measurement, but AVPU scale is still relevant |
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Paed |
For clarity, interobserver reproducibility and ease of documentation modified GCS is more useful than AVPU when serial observations are required |
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PICU |
Yes it CAN be used, and many people do use it |
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Metab |
What do you mean by ‘modified’? Adapted for pre-verbal children was the original meaning |
|
ED |
I suggest that in the Children’s modification, Best Verbal response Cries only to pain (3) and Moans to pain (2) is more useful |
|
ED |
It depends on who is doing the scoring and their understanding of the score they use ie if AVPU used, how many people know that a change of V to P is 2 or more GCS points and equals GCS 8 or less = coma? |
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Neuro S |
Ideally by same assessor |
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PICU N |
AVPU will pick up changes but much less specific |
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Paed |
Most accurate scoring system available |