PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE
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DELPHI PROCESS

Round two

5. Airway assessment

5b) Children with a reduced conscious level should be considered for intubation if:

(i) their Glasgow coma score is less than or equal to 8

Position	Comment
Radiol	Depends on whether they are maintaining their own airway or have head injury etc – too restrictive a guideline ..
Paed ED	Except if post ictal, drunk and therefore likely to recover and can be watched closely meanwhile
Neuro S	Context is important here – the word “considered” is valuable here as children who are simply briefly post ictal or whose GCS is clearly steadily improving are better off watched neurologically without the loss of clinical information consequent on intubation/ventilation
Endo	but there are some circumstances where this wouldn’t be necessary e.g. post ictal, protecting airway and recovering
Neuro	more important is the rate of deterioration
PICU	particularly if no cough / gag / dolls eyes
Metab	I consider this a MUST – avoiding hypoxia is of critical importance

Agreed	Neither agree nor disagree	Disagreed
96%	4%

(ii) their Glasgow coma scale is deteriorating

Position	Comment
Radiol	Depends on how it was deteriorating eg 15-14 no but 6-5 yes
Neuro	Provided it is less than 10
Metab	Depends on starting point
Neuro S	Especially agree if 10 or less. May be worth emphasising that “deteriorating” = a change 2 points or more
Neuro	more important is the rate of deterioration
Paed	depends from what and to – ie if deteriorating below 9 then yes
Metab	but depends of actual level of consc., and the SaO2 also; plus careful monitoring of CNS signs & GCS esp; eg, one might not intub at GCS of say 12-13, but would think seriously if it was, say, 10 and going down

Agreed	Neither agree nor disagree	Disagreed
96%	4%

(iii) their airway obstructs when it is not supported

Position	Comment
ED	Unless the level of consciousness is rising rapidly and therefore the need for airway support is expected to be short-lived.
Paed	Other methods of airway support may suffice eg if immediately post –ictal a Guedel airway may be adequate as improvement can be anticipated over short rather than long time scale
Renal	Presumably you’d use a Guedel airway first off, but if there is no improvement after a short time I would have thought intubation was indicated
Endo	depends on circumstances i.e. probability of imminent improvement
Neuro	unless there is an obvious remedial cause
PICU	would try nasopharyngeal airway especially in child with cerebral palsy

Agreed	Neither agree nor disagree	Disagreed
93%	7%

(iv) their airway is compromised by vomiting

Position	Comment
Neuro	Also empty stomach and have nasogastric tube in place
Renal	Don’t understand what you mean by this question
Paed ED	If GCS 8 and below
Neuro S	Depends on context – if short lived, supervise airway and nurse in recovery position
Neuro	it must be that their airway is compromised, not jus that they are vomiting
Metab	seems most reasonable

Agreed	Neither agree nor disagree	Disagreed
92%	4%	4%

(v) they have signs of raised intracranial pressure

Position	Comment
neuro	This depends upon the signs, conscious level and rapidity in which the RICP has developed (suggested by the history)
Renal	Yes, but experienced anaesthetist to do RSI
Paed ED	and GCS 8 or below
Neuro S	Depends on what the signs are/how acute the history is and whether GCS is stable or improving
Neuro	depends on the clinical context of what the “signs” are

Agreed	Neither agree nor disagree	Disagreed
92%	4%	4%

(vi) their oxygen saturations are less than 92% despite high flow oxygen therapy

Position	Comment
Radiol	Depends on gas analysis not just peripheral sats (ie pH and PaCO2)
Neuro	Might even make the threshold higher
Paed	But assessment for, and correction of, causes of poor oxygenation should be undertaken prior to intubation
Paed ED	depends on cause of low sats, ventilation with V/Q mismatch could make things worse
Neuro S	Must also consider why they are hypoxic
Endo	depends on circumstances
Neuro	Need to know what the cause of the hypoxia is
Paed	check airway position and support that first. If fully supported airway then yes

Agreed	Neither agree nor disagree	Disagreed
73%	15%	12%

(vii) their respiratory rate is inadequate for oxygenation or ventilation

Position	Comment
Paed	Again if simply post ictal they may need a short spell of bagging and recover – anaesthetist should be called however
PICU	not helpful – would suggest hypoxaemia despite Fi)2 >0.6 +/- pCO2 cap/end tidal >0.6
Metab	I am not sure re this Q; really depends on SaO2 more than on RR

Agreed	Neither agree nor disagree	Disagreed
96%	4%	0

(viii) they look exhausted

Position	Comment
Radiol	Difficult to define the criteria
Neuro	This is subjective – would be more dictated by blood gases and other features
PICU	IF ‘EXHAUSTION’ IS FROM RESPIRATORY DISTRESS
Endo	define “exhausted” e.g. respiratory exhaustion. Doesn’t seem a very precise medical term for assessment
Neuro	depends on why they are exhausted and what does look exhausted mean. Too woolly
PICU	Rather subjective – corroborate with observations above
Metab	Too vague a criterion – diff observers will mean diff things by the term

Agreed	Neither agree nor disagree	Disagreed
81%	15%	4%

(ix) they have signs of shock despite initial fluid resuscitation therapy

Position	Comment
Radiol	Depends on ability to maintain own airway and need for ICU care
ED	Comments: Reassess fluid requirements
Paed	Define ‘initial ‘ – does it mean just the first bolus, or more ? I would generally consider intubation after 40 ml/kg
Paed	- provided there is features of shock, despite having had the equivalent of 40ml/kg of IV crystalloid fluids
Neuro	What is initial? Is it simply 10ml/kg bolus or repeated boluses
Paed	>40ml/Kg
PICU	ensure hypoglycaemia corrected and any analgesia too

Agreed	Neither agree nor disagree	Disagreed
64%	25%	11%