PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

2. Observations

Statement 2a (Observations)

Children with a reduced conscious level should have the following observations made

(i) heart rate

% Agree	% Disagree	Result
100%	0 %	Included

(ii) respiratory rate

% Agree	% Disagree	Result
100%	0 %	Included

Statement 2a (Observations)

Children with a reduced conscious level should have the following observations made

(iii) oxygen saturation level

% Agree	% Disagree	Result
100%	0 %	Included

Position	Comments
Neuro S	Need not be continuous if other obs stable

(iv) blood pressure

% Agree	% Disagree	Result
100%	0 %	Included

Position	Comments
ED	I think it needs to be done in conjunction with CRT

(v) continuous cardiac monitoring (E.C.G. leads monitoring rhythm)

% Agree	% Disagree	Result
88.9%	5.5%	Included

Position	Comments
ED P	Preferably, but if not available then HR can be picked up on sats machine
Renal	For significantly impaired consciousness, yes but not for GCS 14
	Depends a little on how low GCS is and how much is known about cause of problem eg if known to be post ictal and not been given drugs and GCS 13- 14 I wouldn’t insist on it.
Paed	they are “ill”

(vi) temperature

% Agree	% Disagree	Result
91.7%	0 %	Included

Position	Comments
ED P	May be relevant to aetiology of the injury
Neuro	All vi should be done if there is no clear etiolgy of reduced consciuos level
ED	Often missed out in trauma! Hypothermia leads to decreased BS leads to decreased GCS, link therefore often missed.
PICU	axilla

Statement 2b

The observations of heart rate, respiratory rate, blood pressure and oxygen saturation level should be recorded at least every hour until the observations and clinical state are stable

% Agree	% Disagree	Result
79.4%	8.8 %	Included

Position	Comments
ED P	More frequently than this if not stable – usually start with every 15 minutes
ED P	Every 15 minutes with neuro obs in initial stages, will be apparent very quickly if can ask for reduced frequency of obs
Paed	Depending on the childs condition, the monitoring may need to be even continuos.
Neuro	it may even need to be done more frequently in the acute state
PICU	The frequency often relates to the underlying condition and the level of GCS
ED	would prefer every 15 mins in the acute phase
Neuro	May need to be performed more frequently if unstable or less frequently if conscious level only mildly impaired
ED	Every 15 mins minimum would be a better statement
PICU	initially every 15mins
Paed	½ hourly

Statement 2c

Children with a reduced conscious level should be observed for changes in consciousness by

(i) a Glasgow coma score recorded every hour

% Agree	% Disagree	Result
62.5%	31.3 %	Excluded

Position	Comments
Paed	More frequently, at least initially
ED P	Every 15 minutes
Paed	Depending on the condition of the child, the recording may need to be more frequent
ED P	More frequently
Metab	Should be more frequent
PICU	There is a problem here in that none of the studies that were done by Teasdale and Jennet in the 1970s (intra- and inter-observer validation etc) have been repeated in children. The closest is the Tatman paper in Archives of Disease in Childhood (the socalled “grimace” modification to the GCS). It is all very well saying that changes should be followed – we have no idea whether the score taken by nurse A is of equal validity to the score taken by nurse B 3 hours later. (This has been formally studied in Nurses and published – repeatability is poor and not influenced by seniority of nurses doing the scoring; it has also been studied in two paediatric neurologists – again level of agreement is poor, see Newton 1995, Dev Med Child Neurol).
ED	more frequently where the patient is unstable
Neuro	This contradicts next statement
PICU	IF GREATER THAN 12
ED	In my experience, children change more frequently quickly than adults therefore Every 15 mins minimum would be a better statement
Endo	More frequently if decreased conscious level. Hourly if normal but at risk eg head injury
Radiol	“at least”
Paed	not frequent enough
Neuro	Useful basic “quick and dirty” assessment
PICU	once stable

Children with a reduced conscious level should be observed for changes in consciousness by

(ii) a Glasgow coma score recorded every 15 minutes if less than or equal to 12; hourly if greater than 12

% Agree	% Disagree	Result
78.8%	9.1 %	Included

Position	Comments
Paed	Certainly until either a diagnosis established or clear trend either to improvement or at least clear there is no deterioration
ED	Suggest GCS check at 15 minute interval for all children with GCS <15 initially (otherwise delay of up to 1 hour before deterioration recognised).
ED P	Probably more frequently in 1^st place
PICU	There is a problem here in that none of the studies that were done by Teasdale and Jennet in the 1970s (intra- and inter-observer validation etc) have been repeated in children. The closest is the Tatman paper in Archives of Disease in Childhood (the socalled “grimace” modification to the GCS). It is all very well saying that changes should be followed – we have no idea whether the score taken by nurse A is of equal validity to the score taken by nurse B 3 hours later. (This has been formally studied in Nurses and published – repeatability is poor and not influenced by seniority of nurses doing the scoring; it has also been studied in two paediatric neurologists – again level of agreement is poor, see Newton 1995, Dev Med Child Neurol)
ED	be guided by clinical cause rather than absolute GCS level
Neuro	depends on situation
ED	If decreased conscious level, stay with every 15 mins ie 13 to 11 over 15 mins is a significant drop
PICU N	Vert much depends on clinical situation and must be a big jump from 1 hour to 15 mins
Paed	sounds reasonable