PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round one

7. Identifying the causes of reduced consciousness

Statement 7a (Problem recognition)

The causes of reduced conscious level in children which can be suspected and treatment initiated within the first hour after presentation include:

(i) shock (hypovolaemic, distributive and cardiogenic) (definition of shock addressed later)

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity

(ii) sepsis (definition of sepsis addressed later)

% Agree	% Disagree	Result
97.1%	2.9%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity

(iii) trauma

% Agree	% Disagree	Result
94.3%	2.9%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity

(iv) raised intracranial pressure (definition of raised intracranial infection addressed later)

% Agree	% Disagree	Result
91.7%	0%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity
Neuro	Sometimes difficult to detect on initial exam

(v) intracranial infection (definition of intracranial infection addressed later)

% Agree	% Disagree	Result
94.3%	0%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity
Neuro S	Meningitis I would include with sepsis as (. Empyemas/abscesses notoriously difficult: would not expect to diagnose in 1 hour
Neuro	Sometimes difficult to detect on initial exam

(vi) metabolic disease (definition of metabolic disease addressed later)

% Agree	% Disagree	Result
76.5%	8.8%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity
Neuro	Inherited metabolic disease are often difficult to detect within the first hour
	Yes to hypoglycaemia, less so in practice for hyperammonaemia etc
Paed	Suspect, yes, precise identification will take much longer, supportive treatment only can be instituted
ED P	Although inborn errors of metabolism are an exception unless patient is known
Neuro S	Not all – hypoglycaemia/addison’s reasonable to think about in 1^st hour
ED P	Can be suspected but not always possible to initiate treatment within 1 hour
Paed	hypoglycaemia – yes. Others highly unlikely to be treated within first hour
Paed	often very difficult to diagnose at time of presentation

(vii) convulsions

% Agree	% Disagree	Result
84.8%	2.9%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity
Neuro	May subtle or electrographic seizures
ED	Should be included within the first hour too

(viii) recovering from a previous convulsion (post-convulsion state)

% Agree	% Disagree	Result
84.4%	3.0%	Included

Position	Comments
Metab	I find this series of questions rather pointless. Of course you CAN suspect and treat within one hour.One thing I am not clear about is whether the child is known to have a pre-existing illness. What matters is how important is it to treat quickly but that will depend in part on the severity
Neuro	There are no distinguishing signs of this state
Endo	?what treatment, except airway support
ED	Should be included within the first hour too

Statement 7b

There may be a group of children with reduced conscious level who have no specific clinical features to aid diagnosis within the first hour of initial presentation

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Paed	Not uncommon scenario!

Statement 7c

In children with reduced conscious level, concurrent management strategies need to be started to treat the different potential causes, whilst waiting for test results to confirm the most likely diagnosis

% Agree	% Disagree	Result
91.2%	0%	Included

Position	Comments
	treat using the ABC criteria first then start with most clinically likely
Paed	Usually possible to exclude some of the potential causes clinically and treat for a smaller group of non excluded causes
ED P	Particularly managment of presumed encephalitis
ED	Not always! – perhaps should say “may need to be started”.
Neuro S	Especially antibiotics to cover sepsis/meningitis
PICU	certainly
Paed	But: care with too much fluid given initially. Too often a reflex response despite little evidence of circulatory failure

Statement 7d

Children with reduced conscious level following a convulsion may be observed for 1 hour after the convulsion has stopped without any tests or treatments, if the patient is stable or improving.

% Agree	% Disagree	Result
57.6%	32.6%	Excluded

Position	Comments
	do a blood glucose
ED	Except for children with known epilepsy and no suspicion of hypoglycaemia, who are otherwise clinically stable or improving
Neuro	depends on context..if no fever/trauma, known epilepsy, usual postictal state
Neuro	This is one of the problems with the over-inclusive definition of non-traumatic coma at the start of the guideline
	Particularly if previous history of convulsions with uncomplicated recovery
PICU	They may have converted to non-convulsive status epilepticus
Metab	A strong response initiated by the expression “without any…..” Not even a capillary blood sugar…..?
ED	depending on the clinical background
Neuro	Only if this occurs in a child with a history of epilepsy or has features of a febrile convulsion
Metab	Needs blood glucose at least
Neuro	I have answered this assuming the impairement of conscious is not severe (GCS > 8) and on the basis of ‘improving’ rather than stable. These are different things. Following a seizure I would expect full recovery within 1 hour in a large majority
ED P	As long as the fit was not focal
ED	Depends on the reason for the fit eg head injury vs febrile vs hypoxic all require focussed Ix and Rx
Neuro S	If known seizure disorder (or a simple febrile fit where temperature has come down)
PICU N	So long as all the assessment bloods have been done and IV access is available
ED N	Depends if they are known to suffer from convulsions
Radiol	Always test for hypoglycaemia
Endo	Bit dependent on whether 1^st fit, febrile, normoglycaemic etc
Metab	“Stable” is a word that can carry several different meanings! Please define…? – This worries me as, if we are wrong, the golden hour has passed
Paed	No tests? what about B.M.
PICU	depends on other features in history
Paed	Most should have a cap glucose checked as a minimum
Neuro	There are very few data in this area and the consequences of getting it wrong are very serious…

Statement 7e (Core investigations for all)

All children with reduced conscious level (except those patients within one hour post convulsion, who are clinically stable) should be investigated with the following tests at presentation:

(i) Capillary glucose

% Agree	% Disagree	Result
100%	0%	Included

Position	Comment
Biochem	Need to define – do you mean a stix test / POCT
Endo	All children including within 1^st hour post convulsion
ED	including post convulsion patients
Neuro	Why not do glucose in the post-convulsive?

(ii) Blood glucose

% Agree	% Disagree	Result
83.3%	2.8%	Included

Position	Comments
ED	where the capillary glucose is not normal
Metab	because of the unreliability of capillary glucose
Paed	Only would do it if the capillary glucose is low
ED P	Only to confirm abnormal cap glucose or if cap glucose not available
ED	I would accept blood glucose from the ABG result too
Paed	Only if capillary glucose abnormal
Biochem	Need to define – do you mean a laboratory glucose?
Metab	Yes, venepuncture blood
Paed	If cap glucose <2.6 or >8
PICU	if cap glucose abn

(iii) Urea

% Agree	% Disagree	Result
76.5%	0%	Included

Position	Comments
Neuro	Creatinine would be my preference
ED	Depends on Differential Diagnosis

(iv) Electrolytes

% Agree	% Disagree	Result
97.1%	0%	Included

Position	Comment
Biochem	Need to define – do you mean Na, K, Ca

(v) Liver function tests - aspartate transaminase/alanine transaminase, alkaline phosphatase, albumin/protein

% Agree	% Disagree	Result
75.8%	0%	Included

Position	Comments
ED	clinical history dependent
ED	Depends on DD
Biochem	? either or both AST /ALT . What about clotting?

(vi) Plasma ammonia (taken from a venous or arterial sample)

% Agree	% Disagree	Result
69.7%	6.1%	Discussed in round 2

Position	Comments
Paed	Would exclude those with obvious diagnosis from history and examination eg trauma, intoxication
Neuro	Depends on context, clinical judgement. Some restrictions of availability out of hours in certain centres
Renal	Not always available out of hours! Needs to be free-flowing sample and to get to lab immediately
ED P	Not in trauma scenario
ED	Depends on DD
Paed	I would not do this at presentation
Endo	If no other cause apparent
PICU	2^nd line

(vii) Plasma lactate

% Agree	% Disagree	Result
33.3%	16.7%	Excluded

Position	Comments
Paed	Would exclude those with obvious diagnosis from history and examination eg trauma, intoxication–
ED P	If there is no other obvious cause, then yes
ED P	Not in trauma scenario
Renal	I think this really only applies to infants/young children in terms of investigations at presentation
Metab	Very non-specific, does not help in deciding on treatment
ED	Depends on DD
Biochem	“All” – will include some patients with known metabolic disease therefore no need to investigate for cause. Investigations limited to precipitation and management. Lactate - Depends on clinical presentation - if patient is shocked, poor periferal circulation, lactate will be increased and difficult to interpret therefore ?value
endo	If no other cause apparent
Paed	I would do this on my cap gas sample
PICU	2^nd line

(viii) Plasma amino acids

% Agree	% Disagree	Result
26.7%	26.7%	Excluded

Position	Comments
Paed	Would exclude those with obvious diagnosis from history and examination eg trauma, intoxication
ED	scenario dependent
ED P	If there is no other obvious cause, then yes
Renal	I think this really only applies to infants/young children in terms of investigations at presentation.
ED P	Not in trauma scenario
ED	Depends on DD
Biochem	Depends if cause of reduced consciousness is known ie may be a known disorder. If not then certainly agree
Endo	If no other cause apparent
Paed	Unlikely to take this on first blood sample
PICU	if not explained therefore 2^nd line

(ix) Blood gas (arterial/capillary/venous) – pH, pCO₂, HCO₃^-

% Agree	% Disagree	Result
94.1%	0%	Included

Position	Comments
ED P	Can be particularly useful for CO2

(x) Full blood count and film – Haemoglobin, white cell count and differential, platelet count

% Agree	% Disagree	Result
90.9%	0%	Included

Position	Comments
Renal	Again, some units (incl GOS when I was there) refuse to do out of hours FBC unless you can specifically justify it
Paed	Yes FBC, no to “film” unless abnormalities on diff count

(xi) Coagulation studies – activated partial thromboplastin time, prothrombin time, fibrinogen, fibrinogen degredation products

% Agree	% Disagree	Result
53.1%	9.4%	Excluded

Position	Comments
Paed	Might omit if clear diagnosis from history /examination and not relevant to that diagnosis
Neuro	Not unless there are other features suggesting a coagulopathy
Renal	Only if sepsis suspected
ED	Depends on DD
PICU N	Yes if there are other clinical indicators
Paed	If suspecting sepsis. Maybe not in all at presentation
Endo	If bruising apparent/haemorrhage likely or confirmed
PICU	2^nd line

(xii) Blood culture

% Agree	% Disagree	Result
88.6%	2.9%	Included

Position	Comments
Neuro	Particularly if the child is febrile
Paed	Omit if not febrile and vlear diagnosis from history/examination
ED	Depends on DD
PICU N	Yes if there are other clinical indicators
Endo	As antibiotics likely to be started until cause known

(xiii) C-reactive protein (if locally available)

% Agree	% Disagree	Result
48.6%	8.6%	Excluded

Position	Comments
Paed	Poor discriminator. Useful if clinically suspect sepsis as a baseline measurement
Neuro	The fact this investigation not available at all centres rather makes a nonsense of the statement?
ED P	Useful guide but must be used appropriately
ED	Depends on DD
PICU N	Yes if there are other clinical indicators
Biochem	What does “local” mean? ?on site ?out of hours
Endo	?may be useful for monitoring disease process

(xiv) blood spot on Guthrie card

% Agree	% Disagree	Result
38.7%	25.8%	Excluded

Position	Comments
Paed	Useful if low glucose, suspect metabolic disease or no obvious diagnosis from history/examination
ED P	Something I suspect is not done often, and we are always forgetting!
Renal	Nice idea but I think it will take some time for A&E units to catch on
Neuro	for acetycarnitine?
ED P	Probably not necessary
ED	Depends on DD
Endo	If no other cause apparent
Biochem	What for? I presume acyl carnitines (same as for (viii)) Why blood spot and not plasma?
Paed	I wouldn’t do this (maybe a good idea?)
Paed	Age related
PICU	2^nd line

(xv) 1 - 2 ml of plasma to be separated, frozen and saved for later analysis if required

% Agree	% Disagree	Result
77.4%	12.9%	Included

Position	Comments
Paed	Useful if low glucose, suspect metabolic disease or no obvious diagnosis from history/examination
ED P	If no clear history of trauma / sepsis
Neuro	Sometimes, not always, particularly not with this very broad definition of coma
Neuro	Always useful in these cases
ED	Depends on DD
Paed	ideally
Neuro S	I’m sure one of (xv) or (xvi) should be saved
Biochem	?specify anticoagulant. ?need to save packed cells
Paed	Age related
PICU	2^nd line

(xvi) 1 - 2 ml of plain serum to be saved for later analysis if required

% Agree	% Disagree	Result
75%	12.5%	Included

Position	Comments
Paed	Useful if low glucose, suspect metabolic disease or no obvious diagnosis from history/examination
ED P	If no clear history of trauma / sepsis
Neuro	Sometimes, not always, particularly not with this very broad definition of coma
ED	Depends on DD
Paed	good for drug levels?
Paed	Age related
PICU	2^nd line

(xvii) Urine for organic acids, amino acids and orotic acid

% Agree	% Disagree	Result
51.4%	14.3%	Excluded

Position	Comments
Neuro	But urine should be saved for these
ED P	If no clear history, esp if parents related. Not in trauma/smoke inhalation
Paed	Useful if low glucose, suspect metabolic disease or no obvious diagnosis from history/examination–
Neuro	Only if a metabolic cause is suspected
Renal	See my comments about amino acids. Urine amino acids are only necessary to diagnose Fanconi syndrome or other amino acid transporter failure – eg Hartnup disease and are not relevant here.
Neuro	Sometimes, not always, particularly not with this very broad definition of coma
ED	Depends on DD
Endo	Store for possible analysis
Biochem	Depends if cause of reduced consciousness is known ie may be a known disorder. If not then certainly agree
Paed	not at presentation
Paed	Age related
PICU	perhaps have age limit <5yrs?

(xviii) Urinalysis for ketones, dextrose, protein, nitrites and leucocytes

% Agree	% Disagree	Result
81.8%	0%	Included

Position	Comments
Neuro	To exclude an infection
Renal	Particularly important if the patient is hypertensive since this will be much quicker than U&E
ED	Depends on DD
Endo	“glucose” better

(xix) Urine for culture

% Agree	% Disagree	Result
57.6%	9.1%	Excluded

Position	Comments
Paed	Only if dipstick positivie for leu and nitrites
Renal	Only relevant if urinalysis positive and/or young infant
ED P	Only if dipstick +ve
ED	Depends on DD
PICU N	Yes if there are other clinical indicators
Paed	dependent on urinalysis results
PICU	some will require
Micro	If urinalysis normal is this required?

(xx) 10ml urine to be saved for later analysis if necessary

% Agree	% Disagree	Result
80%	5.7%	Included

Position	Comments
Paed	Unless diagnosis obvious from history/examination
Renal	Good idea. May be difficult to implement. Will need to be frozen though I think if OA analysis is later requested.
ED	Other tests to include urine antigens and drug screen
ED P	Esp if ?drug ingestion + parents consanguinous
ED	Depends on DD
Endo	Ie metabolic or toxicology
Metab	Does this mean principally for tandem MS or GC-MS? (this is how I’ve interpreted it)
Biochem	Less volume can be useful
Paed	ideally
PICU	generally helpful

(xxi) Throat swab for bacterial culture

% Agree	% Disagree	Result
37.5%	9.4%	Excluded

Position	Comments
ED P	Only if clinically indicated ie not trauma/ingestion
ED	Depends on DD
PICU N	Yes if there are other clinical indicators
Micro	what exactly are we looking for in this situation – isolation of Neisseria meningitides may just indicate colonisation, I think it should be considered but not done in all cases. Group A streptococcus may be relevant if “shocked child” or if Haemophilus sp. if ? epiglottitis. After saying this it is relatively cheap we just need to be clear why it is being done.

(xxii) Cranial Computed Tomography scan

% Agree	% Disagree	Result
51.4%	20%	Discussed in round 2

Position	Comments
Paed	Exclude the occasional case with clear diagnosis not needing scan eg known drug overdose
Neuro	Only if there are localising or laterlising signs
Renal	Not if other clearly identified cause not associated with raised ICP
ED	If cause unclear, or if trauma / intracranial bleed / raised intracranial pressure a possible cause.
ED P	Depends on clinical scenario. Can often wait until preliminary results available unless trauma
Neuro	Not in all
Radiol	While CT is important in the investigation of these children, it is relatively expensive and there are associated risks relating to ionising radiation. In the absence of acute trauma a CT should be a second line investigation once the acute medical causes have been excluded
Paed	Urgency depending upon the presence of 1) signs of raised ICP other than decreased conc level, 2) focal signs
ED	Depends on DD
PICU N	Need to be more specific for CT scan
Neuro S	Not unless neurological signs or unexplained deterioration in GCS while other obs satisfactory
Endo	If no other apparent cause eg hypoglycaemia
Paed	What?!
Paed	Provided there are no other diagnosis in clues
PICU	Needs better selection

(xxiii) Cerebrospinal fluid should be collected if there are no contraindications for lumbar puncture. (Contraindications to lumbar puncture addressed later)

% Agree	% Disagree	Result
72.7%	9.1%	Discussed in round 2

Position	Comments
Paed	Unless diagnosis obvious from history and examination
Neuro	Not in all – there will be contexts in which it is clearly clinically irrelevant. Also depressed LOC a contraindication
Metab	Only if you see the need for doing the LP, of course
Neuro	Except in the case of simple febrile convulsions
Renal	I think in most cases this is more safely done cold
ED	If meningoencephalitis a possibility
ED P	Not in trauma, ingestion. Yes in sepsis
Endo	Probably no urgency in this situation
ED	Depends on DD. If there is an indication to do LP in first place
PICU	CT first
Micro	CSF pressure should be determined

(xxiv) Cerebrospinal fluid should be analysed initially for:

(a) Microscopy

% Agree	% Disagree	Result
100%	0%	Included

Position	Comment
Micro	Cell count

(b) Gram staining

% Agree	% Disagree	Result
100%	0%	Included

(c) Culture and sensitivity

% Agree	% Disagree	Result
100%	0%	Included

(d) Glucose

% Agree	% Disagree	Result
96.9%	0%	Included

(e) Protein

% Agree	% Disagree	Result
93.9%	0%	Included

(f) PCR for herpes simplex and other viruses

% Agree	% Disagree	Result
84.4%	3.1%	Included

Position	Comments
Neuro	Need to specify which common viruses to be sure have been included in local “panel” e.g. HSV 1, HSV 2, VZV, HZV, enteroviruses
Renal	If clinical suspicion only
Paed	I don’t usually do this (maybe good idea)
Neuro S	Results available in reasonable timescale??
Endo	Store for possible analysis
Micro	As long as clinical features are compatible, we try and use markers such as CSF WBC and other findings EEG/CT scan to guide most appropriate PCR investigations. E.g. bacterial PCRs if that is the likely diagnosis.

Statement 7f

(i) As a non-sterile urine sample is required for many of the tests, a urine bag should be in situ as soon as the patient has had monitors attached

% Agree	% Disagree	Result
84.4%	3.1%	Included

Position	Comments
ED P	Although not sent for MC&S, unless no other urine available (useful if negative)
ED	I think this depends on local policy and the reason for and length of decreased GCS. Clean catch vs bag issue
PICU N	Not always a priority
Paed	I want a sterile urine to start with as infection must be excluded
Endo	In young children
PICU	OK

(ii) If a urine sample has not been collected within an hour of presentation, the patient should be catheterised

% Agree	% Disagree	Result
46.9%	28.1%	Included

Position	Comments
ED	If endotracheal intubation and ventilation required
ED P	Can wait a bit longer
ED	Depends on clinical context
Paed	not sure
Neuro S	Monitoring urine output too
Endo	If no inprovement in conscious level
PICU	not always. other intervention Ix 1^st, USS bladder
Paed	?2-3 hours

(iii) If a urine sample has not been collected within an hour of presentation, a patient under one year old should have a suprapubic aspiration of urine performed

% Agree	% Disagree	Result
28.1%	37.5%	Excluded

Position	Comments
Paed	Catheter as good, and may well need catheter anyway
Neuro	Only if infection is suspected
Neuro	I think a catheter would be as appropriate, possibly more in order to measure urine output
ED P	Catheter speciment just as good, although can be difficulties with this sometimes nd then SPA may be attempted (under U/S guidance if poss)
Paed	catheter if possible
ED P	Unlikely to change management. could wait longer or do in/out catheter
Neuro	depends…if you are going to catheterise…you can collect a sa,mple at the same time
ED	Depends on clinical context
Paed	not sure
PICU	not always. other intervention Ix 1^st, USS bladder

Statement 7g (Further investigations for some)

If no diagnosis is made after the first investigations have been reviewed, further tests to request include:

(i) Blood alcohol level

% Agree	% Disagree	Result
58.8%	0%	Discussed in round 2

Position	Comments
Metab	Comments Low glucose, high lactate often useful clues to EtOH ingestion in younger children
Neuro	Not clear whether you mean this should be considered (agreed) or always ordered if initial screen negative (disagree)
Endo	?all ages
Paed	usually obvious from breath
ED P	Dependent on situation
Renal	It would be unusual to cause impaired consciousness without a smell of alcohol on the breath
ED	Depending on clinical suspicion
Neuro	Comments depends on context
ED	I would suggest it ought to be done routinely in all over 12 years if decreased GCS and eg trauma
Biochem	Include in first investigations if history suggests
Paed	usually can smell / have Hx of alcohol
PICU	if suspected from Hx exam this 1^st line

(ii) Urine toxicology screen

% Agree	% Disagree	Result
100%	0%	Discussed in round 2

Position	Comments
Neuro	Not clear whether you mean this should be considered (agreed) or always ordered if initial screen negative (disagree)
Biochem	Include in first investigations if history suggests
PICU	look at pupils/sweatiness if so 1^st line

(iii) MRI (magnetic resonance imaging)

% Agree	% Disagree	Result
37.5%	12.5%	Discussed in round 2

Position	Comments
ED P	Consider
Paed	Would take neurology advice first
ED P	To consider- availability is a problem as will need referral
Renal	Isn’t going to be routinely available
Radiol	If the child has had a normal CT examination that has been reviewed by a consultant radiologist an MRI would be indicated.
Neuro	Only in selected cases
Endo	Not sure much to gain if previously well and normal CT
ED	Depends on clinical context
Neuro S	Not the first place I’d take a sick child – I’d have a CT at this stage
PICU N	Could be useful but I don’t know the specifics
Paed	of brain.
Paed	if CT not available
PICU	rarely required initially unless brainstem suspected / post fossa
neuro	If this is necessary, suggest it should include MR (or in fact CT) venography as the pickup from plain CT is low

(iv) Cerebrospinal fluid Ziehl-Nielsen staining for tuberculosis if the initial microscopy is abnormal

% Agree	% Disagree	Result
62.1%	0%	Discussed in round 2

Position	Comments
Metab	Only if you very strongly suspect TBM. Requires high skill, and in the best hands may be negative in TBM. Certainly not to be ranked above viral culture /PCR in order of importance and doesn’t replace culture for TB
Neuro	A number of alternatives are available; I would be guided by the lab
Neuro	depends on CSF glucose/protein, history and findings
ED P	Can be very non-specific history + exam initially therefore need high index of suspicion
ED	Depends on clinical context
Paed	Consider. In Norwich TBM is rare +++ (no ethnic minorities)
Micro	This should be considered, in practice AAFB microscopy and TB PCR will usually both be performed, PCR is probably more sensitive but the AAFB smear will give you a more immediate answer. Sufficient volumes of CSF are also required, bearing in mind we may have already done the above investigations and the specimen may need to be separated to go to different laboratories.

(v) Cerebrospinal fluid polymerase chain reaction for tuberculosis if the initial microscopy is abnormal

% Agree	% Disagree	Result
63.6%	4.5%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Neuro	Again no longer clear if we’re talking about “if clinical context suggests” or blanket recommendation for every child with a GCS<15 in whom initial investigations unhelpful
Metab	Is this more sensitive than culture for TB?
Neuro	depends on CSF glucose/protein, history and findings
Paed	As above (Consider. In Norwich TBM is rare +++ (no ethnic minorities)) PCR for meningococcus and herpes I would do first
Paed	not available locally
Paed	not available widely and results slow
Micro	This should be considered, in practice AAFB microscopy and TB PCR will usually both be performed, PCR is probably more sensitive but the AAFB smear will give you a more immediate answer. Sufficient volumes of CSF are also required, bearing in mind we may have already done the above investigations and the specimen may need to be separated to go to different laboratories.

(vi) Cerebrospinal fluid amino acids

% Agree	% Disagree	Result
42.1%	21.1%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Neuro	Again no longer clear if we’re talking about “if clinical context suggests” or blanket recommendation for every child with a GCS<15 in whom initial investigations unhelpful. Do you mean further tests “to request” or “to consider requesting”?
Neuro	Only in selected cases
ED P	Be guided by local neurology opinion
Neuro	depends on history, findings and urine AA, OA and serum AA
Paed	Would take neurology advice
Biochem	“consider”! Depends on the clinical findings. Also consider CSF neurotransmitters
Paed	but need blood ammonia, gas etc
PICU	paired samples may be required

(vii) Cerebrospinal fluid lactate

% Agree	% Disagree	Result
58.3%	12.5%	Discussed in round 2

Position	Comments
Neuro	Again no longer clear if we’re talking about “if clinical context suggests” or blanket recommendation for every child with a GCS<15 in whom initial investigations unhelpful. Do you mean further tests “to request” or “to consider requesting”?
Metab	Non-specifically raised in the acute situation
Neuro	Selected cases
ED P	Be guided by local neurology opinion
Neuro	depends on MRI and serum lactate
Metab	Comments In this scenario, interpretation may be impossible
Endo	?only if serum lactate abnormal in an unconscious child
Biochem	Consider at same time as CSF glucose
ED	Depends on clinical context
Micro	We have this in our first line investigations

(viii) Serology for mycoplasma and other viruses

% Agree	% Disagree	Result
73%	0%	Discussed in round 2

Position	Comments
Neuro	if fever
ED	Depends on clinical context
PICU	other
Micro	Some authors have questioned the validity of mycoplasma serology, certainly some of the reported cases in the literature had negative serology. If strongly suspect mycoplasma, CSF for mycoplasma PCR may need to be considered. Please note ureaplasma may cause CNS infection in neonates (usually prem.)

(ix) Autoimmune screen

% Agree	% Disagree	Result
47.8%	4.3%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Paed	Would take neurology advice
Metab	If you suspect SLE, look specifically for this
Renal	Cerebral lupus / vasculitis I presume? An ESR would be a useful screening test before you embark on auto-antibodies
Neuro	as third line…thyroid antibodies, lupus etc
Paed	A positive dsDNA does not mean lupus! You need to suspect an autoimmune condition to request a screen
Endo	If inflammatory markers high ie ESR

(x) Thyroid antibodies and thyroid function tests

% Agree	% Disagree	Result
40.7%	11.1%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Renal	I would have thought thyroid function alone would be sufficient initially
Neuro	as third line
Paed	TFTs yes, antibodies No
Biochem	Review newborn screening for hypothyroidism
Endo	Would expect other clinical findings ie weight change, abnormal heart rate. Only do antibodies if TFTs abnormal

(xi) Thick and thin blood film, if recent foreign travel

% Agree	% Disagree	Result
90.0%	3.3%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Neuro	(But not to Norway! Need to specify)
Metab	Not unless febrile, surely
ED P	I would have this as one of the core investigations if there has been foreign travel as have been caught out before!
Renal	If fever present
Paed	malarial antibody is now our first line test

(xii) Urgent electroencephalogram

% Agree	% Disagree	Result
78.6%	3.6%	Discussed in round 2

Position	Comments
ED	Depends on clinical context
Paed	Would take neurology advice
Neuro	Again no longer clear if we’re talking about “if clinical context suggests” or blanket recommendation for every child with a GCS<15 in whom initial investigations unhelpful. Do you mean further tests “to request” or “to consider requesting”?
Neuro	To exclude non-convulsive status
ED P	Again, entails transfer
Renal	Didn’t realise an EEG could be requested out of hours
Neuro	r/o non convulsive status epilepticus….degree of encephalopathy…clues to etiology
Endo	Esp if confusion persists or localised signs or icreased WCC in CSF
ED P	If suspicion of subclinical status
Paed	if remains unconscious, or fluctuating levels

Statement 7h (Contraindications for lumbar puncture)

Contraindications for lumbar puncture include:

(i) a Glasgow coma score less than 15

% Agree	% Disagree	Result
20%	43.3%	Excluded

Position	Comments
Paed	Higher GCS ( eg 12-14) can be assessed on a case by case basis re signs of raised ICP
Metab	Not before brain imaging
Neuro	On its own it is not a sole contraindication
ED P	Relative CI
Neuro	do CT scan first
PICU	lower threshold =8
Paed	depends on other Ix etc

(ii) a Glasgow coma score less than or equal to 12

% Agree	% Disagree	Result
50.0%	28.1%	Discussed in round 2

Position	Comments
Paed	Again signs and symptoms of raised ICP should be sought
Neuro	do CT scan first
ED	Other signs may be more important – trend of GCS, focal neuro signs, BP etc
Endo	May be deferred
Paed	depends on other Ix etc

(iii) a Glasgow coma score less than or equal to 8

% Agree	% Disagree	Result
73.3%	16.7%	Discussed in round 2

Position	Comments
ED	Other signs may be more important – trend of GCS, focal neuro signs, BP etc
Paed	Context specific. Certainly not soom after arrival in A and E . Can be done once safely intubated and stabilised on PITU
Neuro	do CT scan first
Endo	May be deferred
Paed	depends on other Ix etc

(iv) a deteriorating Glasgow coma score

% Agree	% Disagree	Result
84.4%	12.5%	Included

Position	Comments
ED	Other signs may be more important – trend of GCS, focal neuro signs, BP etc
Paed	Must scan first
Paed	after some period of observation

(v) focal neurological signs

% Agree	% Disagree	Result
84.6%	0%	Included

Position	Comments
Paed	Must scan first
Neuro	New signs
Neuro	do CT scan first
Neuro S	Shifts are a real concern implying risk of herniation
Paed	CT first
Neuro	Depends on GCS

(vi) a focal seizure

% Agree	% Disagree	Result
53.3%	26.7%	Discussed in round 2

Position	Comments
Neuro	do CT scan first
Paed	Must scan first
Neuro	Depends on situation. A fully recovered child who has had a complex febrile seizure may reasonably be LP’d
Paed	complex febrile convulsions (focal prolonged or recurrent) more frequently indicate meningitis. If neurology normal and GCS >12 I would LP)
PICU	until further assessed
Neuro	Depends on GCS

(vii) a seizure lasting more than 10 minutes

% Agree	% Disagree	Result
53.3%	26.7%	Excluded

Position	Comments
Paed	If 10-30 mins assess on basis of other features eg ? raised ICP
Neuro	Until full consciousness is regained
Paed	complex febrile convulsions (focal prolonged or recurrent) more frequently indicate meningitis. If neurology normal and GCS >12 I would LP)
Endo	But could be deferred
PICU	not alone
Paed	until after signs of recovery
Neuro	Depends on GCS

(viii) a seizure lasting more than 30 minutes

% Agree	% Disagree	Result
46.7%	20%	Discussed in round 2

Position	Comments
Neuro	Until full consciousness is regained
Paed	Scan first
Neuro	Ctscan first/exam
Paed	I would delay LP
PICU	would want more investigation
Paed	unless rapid improvement
Neuro	Depends on GCS

(ix) agitation

% Agree	% Disagree	Result
30%	40%	Excluded

Position	Comments
Paed	Sort out agitation first
ED P	Partly as it would be practically difficult
Neuro	will be difficult
Paed	Meningitis ?
Neuro S	Common with meningeal irritation in early stages
PICU	until initial Ix clear +2^nd/3^rd line
Neuro	Depends on GCS

(x) shock (definition addressed later)

% Agree	% Disagree	Result
81.3%	6.3%	Included

Position	Comments
Paed	Wait until stable
Neuro	stabilize first
ED	Treat the shock!
Paed	Yes if unstable, once shock corrected then LP
Neuro	Difficult Qu – as shock can be treated/corrected, then LP done
ED N	Depends on type of shock
Endo	Deferred until resuscitation
Neuro	Depends on GCS

(xi) clinical evidence of systemic meningococcal disease

% Agree	% Disagree	Result
80.6%	9.7%	Included

Position	Comments
Paed	Unless perfectly stable
PICU	you don’t want to be doing an LP in someone with a coagulopathy, but the result will help with treatment, prognosis etc
Renal	Will need LP at some point but not at presentation
Neuro	not necessary….could just treat
Paed	delay because of clotting
Radiol	Blood culture and treat
Neuro	Depends on GCS

(xii) a purpuric rash

% Agree	% Disagree	Result
60%	23.3%	Discussed in round 2

Position	Comments
Paed	Wait until stable and platelet count clotting etc reviewed
Neuro	Depends on the cause of the purpuric rash ?meningococcal, ?low platlets ? effects of vomiting, etc, etc
Neuro	await clotting/platelet count first…no hurry..could treat for meningococcal in mean time
Radiol	Blood cultur and treat
Endo	May be deferred
Paed	check clotting first
Neuro	Depends on GCS

(xiii) pupillary dilation (unilateral or bilateral)

% Agree	% Disagree	Result
86.7%	0%	Included

Position	Comments
Paed	Scan first
Metab	Badly phrased I feel. If unilateral dilation, I would not LP
PICU	AVOID IN ANY LOCALISING SIGNS
ED P	Yes if unilateral, no if bilateral
Metab	Surprised that bi- and unilateral linked in Qu stem. Unilateral pupil dilalation may well be CI
PICU	would do after 1^st line OK

(xiv) papillary reaction to light impaired or lost

% Agree	% Disagree	Result
93.1%	3.4%	Included

Position	Comments
Metab	Certainly not to be done unless you are certain there is not likely to be raised ICP or a mass lesion, but could still be done later if these are excluded
Paed	Scan first

(xv) bradycardia (heart rate less than 60 beats per minute)

% Agree	% Disagree	Result
90%	0%	Included

Position	Comments
PICU	heart rate/blood pressure suggestive of raised intracranial pressure-LP contraindicated
Neuro	Level depends on age
Paed	may indicate raised ICP
Metab	Might depend on its cause – assume not Cushing’s effect
ED N	Depends on normal resting HR +/- signs of shock
Neuro S	(xv) and (xvi): these 2 might be “classical indicators of raised ICP but are very late signs – if seen together that’s concerning – either bradycardia or hypertension alone when GCS is reasonable is less worrying.

(xvi) hypertension (mean blood pressure above 95^th centile for age)

% Agree	% Disagree	Result
85.7%	0%	Included

Position	Comments
Paed	may indicate raised ICP

(xvii) abnormal breathing pattern

% Agree	% Disagree	Result
83.9%	3.2%	Included

Position	Comments
Paed	Intubate and stabilise first
Paed	Not if O2 good, protecting airway, otherwise OK
Metab	Intubate – control airway, LP later
PICU	other interventions more appropriate

(xviii) an abnormal doll’s eyes response (abnormal response is random movement or no movement relative to the eye socket on turning head to left or right, or no upward gaze on flexing neck)

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Metab	Again timing a factor here. Early on: strongly agree strongly. Later, may reflect irreversible damage so could be done without risk
Neuro S	Should get a scan first – if cisterns open proceed to LP

(xix) abnormal posture

% Agree	% Disagree	Result
86.7%	6.7%	Included

Position	Comments
Neuro	Depends on posture
Paed	posturing in meningitis

(xx) signs of raised intracranial pressure (signs of raised intracranial pressure defined later)

% Agree	% Disagree	Result
100%	0%	Included

Position	Comments
Neuro S	Need a scan
Paed	as detailed above

Statement 7i

(i) A normal CT scan does not exclude acute raised intracranial pressure.

% Agree	% Disagree	Result
94.1%	2.9%	Included

Position	Comments
PICU	many papers published on this
Neuro S	But absence of a mass lesion / shift and presence of communication cisterns makes LP safe
Paed	but may be helpful if focal new features

(ii) A normal CT scan should not influence the decision to perform a lumbar puncture if other contraindications are present.

% Agree	% Disagree	Result
81.3%	9.4%	Included

Position	Comments
Paed	Depends on whether scan was purely to look for raised ICP or not eg if scanned because focal fit nad nil focal seen nor raised ICP and child stable, might go ahead
Neuro S	But absence of a mass lesion / shift and presence of communication cisterns makes LP safe

(iii) The decision to perform a lumbar puncture in a child with reduced conscious level should be made by an experienced paediatrician, who has examined the child. (The definition of “an experienced paediatrician” should be decided by individual departments when the guideline is implemented at a local level)

% Agree	% Disagree	Result
94.1%	0%	Included

Position	Comments
ED	could be a paed. A+E consultant too! If experienced/trained to make decision.
Neuro	I think clear guidelines can be drawn up to help juniors make this decision
Paed	SpR (in discussion with consultant)or above