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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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DELPHI PROCESS
Round two
7. Identifying the
causes of reduced consciousness
Core investigations
7e) vi) All children with reduced conscious level (except those patients within one hour post convulsion, who are clinically stable with a normal capillary glucose) should be investigated with the following tests at presentation:
plasma ammonia
|
Position |
Comment |
|
Paed |
Although I take the point that junior staff may find it difficult to distinguish between metabolic and other encephalopathies , I think there are one or two circumstances where one would not need to do this eg obvious meningococcal sepsis or clear evidence of head injury. |
|
Paed ED |
I do think clotting is important maybe not for making diagnosis but may affect care. We do a routine CRP |
|
Endo |
reduced conscious level of unknown cause |
|
Paed |
The problem is that if you have a strong working diagnosis of meningitis or encephalitis (fever , rash, good history etc) you would not do the ammonia as very unlikely to be helpful. Also much less likely to be helpful in the older child as congenital metabolic abnormality would normally present in the under 5s. Do adult physicians do this ? I do NOT think this is a core investigation, but can be done later – in the next hour or so if indicated, |
|
PICU |
Other caveats might include drug O/D – alcohol – i.e. word “unexplained” might help here |
Agreed |
Neither agree nor disagree |
Disagreed |
|
81% |
19% |
0 |
Other investigations
7e (xxii) A cranial CT scan should be considered when the patient is stable if the working diagnosis is:
(a) Sepsis
|
Position |
Comment |
|
Radiol |
Not unless there are signs to suggest intracranial cause or raised ICP – eg abscess etc – CT not justified in ‘meningitis’ alone. |
|
ED |
Not initially |
|
Paed |
Only if also have focal neurological signs |
|
Radiol |
A CT in the presence of sepsis should be performed if suggestion of abscess, mengitis or encephalitis. Should be localising signs. A normal Ct does not exclude meningitis or encephalitis |
|
Paed |
a CT is to be ordered only in those cases where a intracranial focus of infection is suspected. One should also exclude any cases of uncomplicated meningitis |
|
PICU |
Not always if critically low BP was probable cause, if meningitis Yes |
|
Metab |
The point here is – what is the source of the sepsis – is this known? For ordinary sepsis – eg meningoCS per se - we must know why patient has red. consc |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
34% |
28% |
38% |
(b) Raised intracranial pressure
|
Position |
Comment |
|
Neuro |
And no cause for the raised ICP has been identified |
|
Radiol |
How would the diagnosis of RICP be made?. |
|
Metab |
I have had difficulty getting radiologists to accept this. Their view is that imaging doesn’t measure ICP and may be normal in raised ICP (both true, of course). I think they misunderstand the questions being put to them. The clinician’s view is that he wants a scan to help determine a cause for raised ICP, and also, in some cases, (suspect meningitis , for example), to know if there is a focal lesion or hydrocephalus which would contra indicate an LP, or require immediate surgical intervention |
|
Paed |
after the necessary steps have been put in place to correct the raised intracranial pressure, then a imaging could be done, if a intracranial Space occupying lesion is suspected |
|
Neuro |
but we need to beware of normal early CTs |
Agreed |
Neither agree nor disagree |
Disagreed |
|
97% |
3% |
0 |
(c) Bacterial meningitis
|
Position |
Comment |
|
ED |
Not an immediate priority |
|
Neuro |
Definitely needed if coma prolonged e.g. to exclude hydrocephalus, collections |
|
Paed |
Variable. eg If child has GCS of 12 or more and definite evidence of meningitis and its late at night I might well wait and see how things are in the morning as its unlikely in that situation the CT would alter management acutely. |
|
Radiol |
A CT is not indicated in all children with meningitis. A normal Ct does not exclude the diagnosis |
|
Metab |
less strongly positive in this response because a period of waiting may be in order, after treatment has started |
|
Endo |
in context of decreased conscious level |
|
Metab |
once therapy begun, may wish to wait for 12-24 hours prior to CT; but bacteriol may be important as TBM or pneumoC men may pose a greater risk of brain dam or death than meningoC, eg. If in doubt on basis of GCS etc (see above) CT immediately |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
47% |
37% |
16% |
(d) Herpes simplex encephalitis
|
Position |
Comment |
|
Radiol |
Treat first investigate later – MR better than CT (CT may be false –ve), but MR limited availability |
|
ED |
Consider MRI/CT |
|
Neuro |
MRI better, unusual to make this diagnosis with any degree of certainty acutely |
|
Paed |
MRI much preferable but in reality ( eg weekend ) CT might be more immediately available and may help either raise or lower suspicion of HSE. |
|
Radiol |
A Normal CT does not exclude the diagnosis. In all cases the CT should be only requested if it would alter management . MRI is more suitable. |
|
Renal |
I would have thought MRI was better |
|
Metab |
Not sure what the ideal timing should be (delayed to allow signs to appear) or if the appropriate test should be MRI rather than CT |
|
Neuro |
Would prefer an MRI |
|
Paed |
You could argue that this will be helpful later on in the illness. LP and EEG required early |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
70% |
20% |
10% |
(e) Prolonged convulsion
|
Position |
Comment |
|
Neuro |
Only if there are focal features |
|
Paed |
Exclude those with past history of epilepsy and prolonged convulsions |
|
Endo |
depends on circumstances e.g. if known to have fits |
|
Neuro |
depends on the context and what is meant by prolonged |
|
PICU |
and any focal convulsion |
|
Metab |
one assumes this means > 30 mins; but is there not an overlap with resp b) above |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
67% |
22% |
11% |
(f) Cause unknown
|
Position |
Comment |
|
PICU |
after initial bloods back |
|
Metab |
may be diagnostic |
Agreed |
Neither agree nor disagree |
Disagreed |
|
97% |
0 |
3% |
7e)(xxiii) A lumbar puncture should be performed, when no acute contraindications exist, if the clinical working diagnosis is:
(a) Sepsis
|
Position |
Comment |
|
Neuro |
To detect concmittant meningitis |
|
Paed |
Should change statement to make it quite clear that contraindications include being an unstable septic patient. Resuscitation and antibiotics take priority over LP |
|
Paed |
If a child is unconcious I would be unhappy to perform an LP acutely, possibly excluding neonate / infant. |
|
Endo |
although I wouldn’t if strong indications of meningococcus e.g. purpura |
|
PICU |
core investigations back; stable patient; CT done |
|
Metab |
- only if source of sepsis not clear nor strongly suspected |
Agreed |
Neither agree nor disagree |
Disagreed |
|
77% |
15% |
8% |
(b) Bacterial meningitis
|
Position |
Comment |
|
Neuro |
May need to be delayed |
|
Paed |
If a child is unconcious I would be unhappy to perform an LP acutely, possibly excluding neonate / infant. |
|
Neuro |
Care needed if thought to have RICP. need to make sure other ways of finding the bacteria are done |
|
Metab |
are we simply treating in blanket fashion? Not convinced that is nec or fully safe |
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
0 |
4% |
(c) Herpes simplex encephalitis
|
Position |
Comment |
|
Paed |
If a child is unconcious I would be unhappy to perform an LP acutely, possibly excluding neonate / infant. |
|
Metab |
not convinced of wisdom or necessity; start therapy and wait |
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
0 |
4% |
(d) Tuberculous meningitis
|
Position |
Comment |
|
Paed |
If a child is unconcious I would be unhappy to perform an LP acutely, possibly excluding neonate / infant. |
|
Metab |
not convinced of wisdom or necessity; start therapy and wait - in TBM patients in my exp may well get worse with coning some time before improvement slowly begins to show – so great caution! |
Agreed |
Neither agree nor disagree |
Disagreed |
|
92% |
4% |
4% |
(e) Cause unknown
|
Position |
Comment |
|
Paed |
If a child is unconcious I would be unhappy to perform an LP acutely, possibly excluding neonate / infant. |
|
Endo |
depends on clinical progress |
|
Metab |
may be diagnostic in some cases; as long as no CI (as stated above) |
Agreed |
Neither agree nor disagree |
Disagreed |
|
86% |
7% |
7% |
Contraindications for lumbar
puncture
7h) A lumbar puncture should be deferred or not performed as part of the initial acute management in a child who has:
(ii) a Glasgow coma score less than or equal to 12
|
Position |
Comment |
|
Radiol |
Comments CT first to exclude other causes, blood cultures and treat prior to CT and LP |
|
Neuro |
This level of conscious would not preclude a LP with out other features of RICP or agitation |
|
Neuro |
suggest add ‘and is afebrile’ and perhaps add something about stability e.g. unventilated |
|
Paed |
Stabilise and perform other assessments first., then reassess need for LP |
|
Metab |
Difficult to be specific here. I tend to do rather than to not do, but don’t use a specific GCS number as a guide. More seat of the pants I’m afraid |
|
Paed |
I might do it scoring 12 or even 11 but not if less and not if any suspicion of raised ICP |
|
PICU |
Many will be able to have LP |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
48% |
40% |
12% |
(iii) a Glasgow coma score less than or equal to 8
|
Position |
Comment |
|
Neuro |
I have been caught out even in ventilated patients…LP should be done if afebrile |
|
Metab |
Difficult to be specific here. I tend to do rather than to not do, but don’t use a specific GCS number as a guide. More seat of the pants I’m afraid |
|
PICU |
CT first – LP – If so consider urine and blood for Ag screen and PCR |
Agreed |
Neither agree nor disagree |
Disagreed |
|
88% |
8% |
4% |
(v) a focal seizure
|
Position |
Comment |
|
Neuro |
I would do if febrile and recovering consciousness |
|
Paed |
Depends on context. If GCS > 12 and no focal signs I would do so. |
|
Paed |
Should be delayed |
|
Neuro |
Why would one want an LP in the acute situation? |
|
PICU |
CT first always |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
74% |
19% |
7% |
(vi) a seizure lasting more than 10 minutes and has a GCS less than or equal to 12
|
Position |
Comment |
|
Neuro |
These features on their own would not necessarily prevent a LP |
|
Paed |
Need upper time limit – lasting more than 10 but less than 30 mins |
|
Metab |
– may be non-specific; post-ictal merely. Identical with prev question |
Agreed |
Neither agree nor disagree |
Disagreed |
|
76% |
16% |
8% |
(vii) a seizure lasting more than 10 minutes and has not regained full consciousness
|
Position |
Comment |
|
Paed |
Depending upon rate of improvement |
|
Paed |
If you need to do an LP, it is often easier when the child is a little post ictal |
|
Metab |
– may be non-specific; post-ictal merely |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
64% |
12% |
24% |