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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Round two
16. No clinical clues to cause
16 (ii) In a child with a reduced conscious level and there are no clinical clues to the cause the following tests (as well as the core investigations) should be requested:
(a) CT scan
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
|
Paed |
I would do an MRI in preference if there were NO clues |
|
PICU |
urgency and timing depend on clinical features. Full history important |
Agreed |
Neither agree nor disagree |
Disagreed |
|
93% |
0 |
7% |
(b) a lumbar puncture, if no acute contraindications exist
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
Agreed |
Neither agree nor disagree |
Disagreed |
|
86% |
10% |
4% |
(c) an urgent EEG
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. and less likely than other tests in this section to be diagnostic |
|
Paed |
Unobtainable |
|
Neuro |
Depends what is meant by urgent. Within 4 hours might be appropriate |
|
Neuro |
How urgent is urgent? |
|
PICU |
timing depends on clinical presentation |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
52% |
40% |
8% |
(d) urine toxicology screen
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
|
Biochem |
Specimen should be taken but tests not necessarily undertaken – depends on results of core tests |
|
Endo |
at least have samples stored for |
|
PICU |
and save urine |
Agreed |
Neither agree nor disagree |
Disagreed |
|
97% |
3% |
0 |
(e) urine organic acids
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. AND Possibly not necessary on older patients ( teenagers) |
|
Paed ED |
guided by history and examination |
|
Paed |
Save urine |
|
PICU |
DEPENDS ON AGE, PH ETC |
|
Biochem |
Specimen should be taken but tests not necessarily undertaken – depends on results of core tests |
|
Endo |
at least have samples stored for |
|
Neuro |
especially in a young child |
Agreed |
Neither agree nor disagree |
Disagreed |
|
76% |
20% |
4% |
(f) urine amino acids
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’ AND Possibly not necessary on older patients ( teenagers). |
|
Paed ED |
guided by history and examination |
|
Paed |
Save urine |
|
PICU |
DEPENDS ON AGE, PH ETC |
|
Biochem |
Specimen should be taken but tests not necessarily undertaken – depends on results of core tests |
|
Endo |
at least have samples stored for |
|
Neuro |
especially in a young child. Do you need an age cut-off? |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
72% |
20% |
8% |
(g) plasma amino acids
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. AND Possibly not necessary on older patients ( teenagers) |
|
Paed ED |
guided by history and examination |
|
Paed |
Save serum |
|
PICU |
DEPENDS ON AGE, PH ETC |
|
Biochem |
Specimen should be taken but tests not necessarily undertaken – depends on results of core tests |
|
Endo |
at least have samples stored for |
|
PICU |
can await urine |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
57% |
39% |
4% |
(h) plasma lactate
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
|
PICU |
DEPENDS ON AGE, PH ETC |
|
Neuro |
especially in a young child, but?in older child |
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
4% |
0 |
(i) serology for mycoplasma
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
|
Micro |
Mycoplasma serology may not be accurate in diagnosing mycoplasma encephalitis, we would suggest only performing this investigation if CXR or other clinical features suggestive of mycoplasma. I would also discourage the use of macrolides in this group of patients because they penetrate CNS poorly |
|
Paed |
I would probably do it but mycoplasma highly unlikely to be the sole cause of the problem |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
67% |
19% |
14% |
(j) ESR
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. AND Unlikely to advance diagnosis. If really worried about inflammatory and/or vasculitic processes need to add screen for relevant antibodies in addition to esr |
|
Endo |
if any clinical features of vasculitis, but then presumably also autoantibodies |
|
Paed |
cerebral vasculitis and other inflammatory conditions |
Neither agree nor disagree |
Disagreed |
|
|
68% |
20% |
12% |
(k) Thyroid function test
|
Position |
Comment |
|
Paed |
Not clear whether you mean requested at the same time as core investigations or requested if still no clue as to diagnosis after core investigations. If at same time as core investigations I would prefer to see stem changed to ‘considered’ rather than ‘requested’. |
|
PICU |
RARE AS HEN’S TEETH (HASHIMOTO’S ENCEPHALITIS) – CERTAINLY IN ADOLESCENT GIRLS, OR FAMILY HISTORY OF THYROID DISEASE |
|
Biochem |
Not familiar with the evidence |
|
Endo |
pretty rare though – not sure I’d do it first unless suspicious clinical features preceding episode |
|
Metab |
– such a child is likely to have an environmental cause for the red. L of C |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
71% |
25% |
4% |