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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Round one
6. Breathing assessment
Statement 6a (Breathing management)
(i) Children with a reduced conscious level should be treated with high flow oxygen, regardless of their oxygen saturation level.
|
%
Agree |
%
Disagree |
Result |
|
51.7% |
31.0% |
Excluded |
|
Position |
Comments |
|
Paed |
Depends on cause of decreased conscious level . Yes if any concerns re cerebral perfusion. Not for many others eg alcohol intoxication |
|
PICU |
Again this will depend on the underlying physiology. The obtunded patient with cystic fibrosis presenting with hypercapnic acidosis may deteriorate further with high flow oxgen (because of hypoxic drive to ventilation). |
|
ED P |
Yes in acute phase, otherwise O2 to maintain sats |
|
Neuro |
Pretty improbable admittedly, but the one danger of this approach is to miss a child who’s drowsy through hypoventilation/CO2 retention, where low oxygen saturation (in air) may be important indicator |
|
PICU N |
It depends, if in the initial assessment, then yes give O2 – if not and the SpO2 is OK then not necessarily |
|
Paed |
if tolerated (mask etc) |
|
PICU |
if sats in air 93% + OK |
|
Neuro |
There are dangers associated with oxygen: this may need an RCT |
(ii) Children with a reduced conscious level should be treated with high flow oxygen if their oxygen saturations are less than 95%.
|
%
Agree |
%
Disagree |
Result |
|
77.4% |
9.7% |
Included |
|
Position |
Comments |
|
PICU |
OXYGEN GIVEN IRRESPECTIVE OF SATURATIONS |
|
Endo |
Give O2 in case of metabolic acidosis leads to decreased cell perfusion |
|
PICU |
93% |
Statement 6b
(i) Children with a reduced conscious level should be intubated and ventilated if their oxygen saturations are less than 95% despite high flow oxygen therapy.
|
% Agree |
%
Disagree |
Result |
|
45.2% |
22.6% |
Excluded |
|
Position |
Comments |
|
Paed |
Depends on why sats havent come up – need to search for additional lung pathology etc |
|
Neuro |
Decision for intensivist |
|
PICU |
There are physiological reasons for supporting patients with mechanical ventilators: presumably you are alluding to the possibility of intrapulmonary shunt or VQ mismatch here. A saturation below 95% is not significant |
|
ED P |
May accept slightly lower sats than risk complications of intubation and ventilation with possible V/Q mismatch etc |
|
Neuro |
Depends upon the cause of hypoxia |
|
Neuro S |
More important to x-ray chest/think about causes of hypoxia than intubate |
|
ED |
Probably, unless there is a rapidly reversible cause for hypoventilation, eg opioid poisoning. |
|
ED |
This decision needs to be taken in the clinical context. eg in hypovolaemia may need volume +++ and intubation may be unnecessary |
|
ED N |
Depends if use of other adjuncts or suction raise oxygen saturations |
|
PICU N |
Very much depends on the situation |
|
Endo |
Again depends on cause/likely rapid progress |
|
Paed |
Need to assess airway + breathing + circulation correct these |
(ii) Children with a reduced conscious level should be intubated if their oxygen saturations are less than 92% despite high flow oxygen therapy.
|
%
Agree |
%
Disagree |
Result |
|
66.7% |
1.7% |
Excluded |
|
Position |
Comments |
|
PICU |
What is the physiology |
|
ED |
Probably, unless there is a rapidly reversible cause for hypoventilation, eg opioid poisoning. |
|
ED |
This decision needs to be taken in the clinical context. eg in hypovolaemia may need volume +++ and intubation may be unnecessary |
|
PICU N |
Situational! |
|
Paed |
As above (Need to assess airway + breathing + circulation correct these) airway positioning. May need intubation if breathing inadequately (CO2 retention on gas etc) |
|
ED N |
Depends if use of other adjuncts or suction raise oxygen saturations |
|
Neuro S |
More important to x-ray chest/think about causes of hypoxia than intubate |
(iii) Children with a reduced conscious level should be intubated if the child looks exhausted.
|
%
Agree |
%
Disagree |
Result |
|
81.3% |
6.3% |
Included |
|
Position |
Comments |
|
ED |
This decision needs to be taken in the clinical context. eg in hypovolaemia may need volume +++ and intubation may be unnecessary Rx may improve things Senior anaesthetic/medical input essential |
|
Neuro |
BUT I’m not sure the qu is precise enough - ?”looks exhausted” is somewhat subjective |
|
Paed |
correct ABC |
|
PICU |
exhausted unhelpful |
(iv) Children with a reduced conscious level should be intubated if there are signs of shock. (The signs of shock will be addressed later)
|
%
Agree |
%
Disagree |
Result |
|
62.5% |
9.4% |
Excluded |
|
Position |
Comments |
|
ED |
This decision needs to be taken in the clinical context. eg in hypovolaemia may need volume +++ and intubation may be unnecessary Rx may improve things Senior anaesthetic/medical input essential |
|
Neuro |
Need to qualify with an indicator of severity |
|
ED P |
possibly- depends on aetiology and response to fluid treatment,,and amount of fluid used |
|
ED P |
Only if unresponsive to initial fluid therapy |
|
PICU N |
Depends on situation, but most of the time |
|
Endo |
Depends on response to early treatment |
|
PICU |
initial response = volume +check glucose |
|
Paed |
but treatment of shock should be ongoing |