PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE

PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

5. Airway assessment

Statement 5a (Airway management)

Children with a reduced conscious level are at risk of airway obstruction

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Neuro	Depends on the level of consciousness
ED	Depends on the GCS. 8 or less, definitely. In adults there is evidence that if GCS decreased due to poisoning airway threatened even if GCS > 8 (Penny Cook, late 1980’s/early 1990’s). ?similar in children.
PICU	and apnoeas/hypopnoea. Attendants must be prepared

Statement 5b

(i) Children with a Glasgow coma score of 8 or less should be intubated and ventilated to protect their airway.

% Agree	% Disagree	Result
79.3%	3.4%	Discussed in round 2

Position	Comments
Neuro	not always….it is a guideline..but not always necessary…monitoring closely is necessary-
ED P	Not necessarily, eg if post-ictal, alcohol intoxication, it can be monitored closely re airway. Depends on anticipated recovery time and level of available supervision
Neuro	Assuming we are dealing with an acute situation
ED P	Intubation should be considered (especially in absence of gag reflex) and the presence of an anaesthetist requested
Neuro	Or at least assessed by senior paediatric anaesthetist/intensivist
PICU	If the child is being transferred to another hospital or the CT scan then yes. However, if the patient can protect their airway and they have good respiratory drive then it may not be necessary
Metab	guarded position here: why 8?
Neuro	A lot of children who have this depth of coma do not require immediate ventilation
Endo	Depends a bit on likely cause eg if post ictal, rapid recovery may occur with simple support
ED	Unless rapidly reversible cause (eg treatment for opioid poisoning or hypoglycaemia).
ED	It depends on why GCS < 8 and trend eg fitting child to post ictal child recovery may not need it
PICU N	However, the whole circumstances do need to be taken into consideration
PICU	and allow CT
Paed	post ictal children can safely be managed by close clinical observation and intubation only performed if not getting better

(ii) Children with a reduced Glasgow coma score should be intubated if their airway obstructs when it is not supported.

% Agree	% Disagree	Result
87.1%	3.2%	Discussed in round 2

Position	Comments
Metab	Qualified yes here: support or a pharyngeal airway may be better than intubation
PICU	GCS does not come into this statement at all – any child with airway obstruction will require some form of airway support or intervention. It depends on the underlying physiology – loss of nasopharngeal tone, etc
Neuro	Or at least assessed by senior paediatric anaesthetist/intensivist
Paed	Depends on context and how much support is needed eg post ictal child managing perfectly well with Guedel airway who one expects to lighten up quickly might bemanaged by Guedel and close observation from appropriately trained staff
Neuro	Comments better would be to do it before the airway obstructs
ED	Unless rapidly reversible cause (eg treatment for opioid poisoning or hypoglycaemia).
ED	It depends on why GCS < 8 and trend eg fitting child to post ictal child recovery may not need it and it shouldn’t be unsupported if airway being done properly
Paed	Not if airway adjunct can open the airway sufficiently – may need this for short term until recovered from seizure
Neuro S	Guedel airway adequate if transient obstruction and GCS improving esp post-ictal
Paed	Unless immediately post ictal

(iii) Children with a reduced conscious level should be intubated if they are vomiting.

% Agree	% Disagree	Result
72.4%	13.8%	Discussed in round 2

Position	Comments
ED	Depends on GCS and whether or not confident child can protect his/her airway, and on likely course of illness (eg greater readiness to intubate if anticipate GCS likely to deteriorate).
ED P	Yes if not protecting their airway (ie GCS < 8) ?clarify this statement by adding gag reflex intact, then I would say no
Paed	Unless GCS only minimally reduced eg 13 or 14 and good reason to suppose will imrpove quickly
Neuro	Depends on how depressed their conscious level is and their ability to protect their airway
ED P	Depends on level of obtundation, should be considered
Neuro	at least assessed by senior paediatric anaesthetist/intensivist
NeuroS	Try protecting airway and nursing on side first
PICU	Certainly if they cannot protect their airway
ED	It depends on why GCS < 8 and trend eg fitting child to post ictal child recovery may not need it. Good suction and positioning should be starting point
PICU N	How severe, the GCS
Endo	recurrently
Paed	not if GCS is 14 – 10ish as can protect own airway
PICU	generally
Paed	Conc level <8 and vomiting – agree. Initial simple airway clearance

(iv) Children with a reduced conscious level should be intubated if they have no cough (gag) reflex.

% Agree	% Disagree	Result
90.3%	3.2%	Discussed in round 2

Position	Comments
ED	Unless rapidly reversible cause (eg treatment for opioid poisoning or hypoglycaemia). Depends on GCS and whether or not confident child can protect his/her airway, and on likely course of illness (eg greater readiness to intubate if anticipate GCS likely to deteriorate)
Neuro	Or at least assessed by senior paediatric anaesthetist/intensivist
Paed	No as above ( not if GCS is 14 – 10ish as can protect own airway) – may tolerate geudel airway if seizing or post-ictal for short while without gagging. Cannot intubate all of these immediately
Radiol	?shouldn’t test for gag reflex – may induce vomiting
Paed	Unless immediately post ictal

(v) Children with a reduced conscious level should be intubated if they have signs of raised intracranial pressure. (Signs of raised intracranial pressure will be addressed later)

% Agree	% Disagree	Result
72.7%	3.0%	Discussed in round 2

Position	Comments
Neuro	Depends upon which signs and depth of coma
Neuro	The very mildest degrees (Coma score of 13 or 14 may not requires intubation
ED	Depends on GCS, likely course, and acuity of presentation
ED P	Depends also on GCS
ED	Although if you mean raised BP, decreased pulse rate and eye signs, it may raise questions about earlier ABC Mx to decrease raised ICP, or it may represent severity of injury, ie don’t wait for raised ICP signs for decision to intubate is the important message
Paed	depends on GCS – if <8 then yes. May have raised ICP with benign intracranial hypertension etc
Endo	“not previously apparent”
Neuro S	Depends on the GCS – down to 8, retaining clinical information about GCS/neurological deficits may be more valuable
PICU	not all – some will require observation under treatment eg DKA / meningitis