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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Round three
12. Intracranial
infections
Bacterial meningitis
12 a) i) Children with bacterial meningitis do not always present with neck stiffness.
|
Position |
Comment |
|
Micro |
Signs may be minimal in an infant or may occur late (importance of repeat examination), may not be elicited in comatose patients and those with focal or diffuse neurological impairment. In one study of 1064 patients only 16(1.5%) had no meningeal signs during entire hospitalisation. Geiseler PJ South Med J 75:448-50, 1982 |
|
Renal |
Particularly younger children (under 2 years) |
|
paed |
Important to include this as guideline applicable to infants as well as older children |
|
paed |
This is a real possibility in a child who might have been treated with a course of oral antibiotic for a suspected URTI and then presents to us with a partially treated meningitis. In this case a recent history of antibiotic use would be very useful. |
|
Paed ED |
especially younger age group |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
4% |
0% |
12 a) ii) Children with reduced conscious level but no neck stiffness should be suspected of having bacterial meningitis clinically if they have fever and one of the following:
rash
irritability
bulging fontanelle
|
Position |
Comment |
|
Micro |
This would be my preferred recommendation as it is the most inclusive. |
|
paed |
Should we specify type of rash ??? |
|
metab |
Absolutely!! |
|
neuro |
This is highly age dependant |
|
Neuro s |
This might include a lot of
febrile , fed up kids- it depends on the GCS |
|
ED |
Since it is potentially reversible, consider it with a low
risk threshold |
|
neuro |
Seizures in any age range |
|
paed |
only IF THE RASH IS NON BLANCHING |
|
PICU |
reduced conscious level and fever
sufficient to consider the diagnosis and treatment |
|
Paed ED |
Please specify the rash The wording is not ideal in any of these three examples- what about- if they have a fever and one or more of the following- irritability should be weighted more that the others |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
67% |
25% |
8% |
12 a) iii) Children with reduced conscious level but no neck stiffness should be suspected of having bacterial meningitis clinically if they have fever and two of the following:
rash
irritability
bulging fontanelle
|
Position |
Comment |
|
neuro |
This is highly age dependant |
|
neuro s |
This is probably a more sensible
rule |
|
paed |
I
WOULD ACCEPT IRRITABILITY OR BULGING FONTANELLE IN THE PRESENCE OF REDUCED CONCIOUSNESS
AS SUFFICIENT TO SUSPECT MENINGITIS WITHOUT RASH ETC. |
|
Endo |
It should always be considered in infants with fever
regardless of how many other signs/symptoms unless another diagnosis is
apparent |
|
PICU |
reduced conscious level and fever
sufficient to consider the diagnosis and treatment |
|
Paed ED |
Please specify the rash The wording is not ideal in any of these three examples- what about- if they have a fever and one or more of the following- irritability should be weighted more that the others |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
75% |
12.5% |
12.5% |
12 a) (iv) Consider bacterial meningitis in children with a reduced conscious level without neck stiffness if they have a fever, a rash, a bulging fontanelle and or they are irritable.
|
Position |
Comment |
|
paed |
I marginally prefer the wording in iii above |
|
metab |
For sure |
|
metab |
This is the woolliest choice – any or all? |
|
paed |
I WOULD PREFER NON BLANCHING RASH |
|
Endo |
It should always be considered in infants with fever
regardless of how many other signs/symptoms unless another diagnosis is
apparent |
|
PICU |
treat for bact meningitis, not
consider |
|
Paed ED |
Please specify the rash The wording is not ideal in any of these three examples- what about- if they have a fever and one or more of the following- irritability should be weighted more that the others |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
83% |
8% |
9% |
Herpes simplex encephalitis
12b (ii) Herpes simplex encephalitis should be suspected clinically in a child with a reduced conscious level (and therefore aciclovir started) if:
(a) the child has had a prolonged convulsion with no obvious precipitating cause
|
Position |
Comment |
|
Micro |
? persistent seizures a better phrase, suggests lack of response to Rx |
|
Paed |
I agree with the statement as it stands but find this confusing - if we are saying that acyclovir will be started if the cause of diminished consciousness is not known then this statement is superfluous. It suggests one might be looking for a cause of prolonged seizures which is distinct from the cause of the diminished consciousness. Surely life isn’t that complicated ! If the only purpose of incliding the stamtent is to add acyclovir I personally would leave this out. If its to make people consider the diagnosis and relevant additional tests then I can see the sense in leaving it in. Needs clarification |
|
Neuro |
The point is that herpes simplex encephalitis presents with very insidious features in many cases. If we are to give effective treatment early on I can see no other appropriate strategy other than to treat all encephalopathic children in whom there is no other cause with acyclovir |
|
paed |
Wont give acyclovir if there is no history of fever and child is known epileptic or has developmental delay. |
|
Endo |
?>5years old – otherwise started in quite a few
“bening” febrile convulsions probably |
|
PICU |
- convulsion with background (ie
before fit) reduced conscious level OK - febrile convulsion NO - ?count
as precipitating cause |
|
Neuro |
but depends on age of child. If febrile convulsion age range probably not |
|
ED |
Have done more reading now! Morbidity high even with treatment. No pathognomonic findings therefore treat early (relatively non-toxic) pending confirmation of diagnosis to reduce mortality and morbidity. |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
63% |
29% |
8% |
(b) the child has focal neurological signs
|
Position |
Comment |
|
paed |
If other causes excluded but that brings me back to comments in (a) above… I agree with the statement as it stands but find this confusing - if we are saying that acyclovir will be started if the cause of diminished consciousness is not known then this statement is superfluous. It suggests one might be looking for a cause of prolonged seizures which is distinct from the cause of the diminished consciousness. Surely life isn’t that complicated ! If the only purpose of incliding the stamtent is to add acyclovir I personally would leave this out. If its to make people consider the diagnosis and relevant additional tests then I can see the sense in leaving it in. Needs clarification |
|
ED |
get a CT |
|
Virology |
Providing there is no evidence of raised ICP the CSF is likely to be helpful, although in the very early stages it may be normal and negative for HSV by PCR.. Imaging may be helpful prior to treatment is this can be done very rapidly |
|
Neuro |
if imaging doesn’t reveal anything else |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
84% |
8% |
8% |
(c) the child has had a fluctuating conscious level for 6 hours or more
|
Position |
Comment |
|
paed |
Head injury excluded, but see (a) I agree with the statement as it stands but find this confusing - if we are saying that acyclovir will be started if the cause of diminished consciousness is not known then this statement is superfluous. It suggests one might be looking for a cause of prolonged seizures which is distinct from the cause of the diminished consciousness. Surely life isn’t that complicated ! If the only purpose of incliding the stamtent is to add acyclovir I personally would leave this out. If its to make people consider the diagnosis and relevant additional tests then I can see the sense in leaving it in. Needs clarification |
|
Virology |
Providing there is no evidence of raised ICP the CSF is likely to be helpful, although in the very early stages it may be normal and negative for HSV by PCR.. Imaging may be helpful prior to treatment is this can be done very rapidly |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
79% |
17% |
4% |
d) the child has had two or more of the following:
a prolonged convulsion with no obvious precipitating cause
focal neurological signs, including a focal convulsion
a fluctuating conscious level for 6 hours or more
|
Position |
Comment |
|
Paed |
I agree with the statement as it stands but find this confusing - if we are saying that acyclovir will be started if the cause of diminished consciousness is not known then this statement is superfluous. It suggests one might be looking for a cause of prolonged seizures which is distinct from the cause of the diminished consciousness. Surely life isn’t that complicated ! If the only purpose of incliding the stamtent is to add acyclovir I personally would leave this out. If its to make people consider the diagnosis and relevant additional tests then I can see the sense in leaving it in. Needs clarification |
|
neuro s |
This seems sensibly selective |
|
Endo |
Can always be stopped before course completed, if rapid
recovery |
|
Paed ED |
I don’t think you should specify the number of events as one by itself can be indicative, so I would go with the first lot of statements |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
92% |
8% |
0% |
d) the child has had all of the following:
a prolonged convulsion with no obvious precipitating cause
focal neurological signs, including a focal convulsion
a fluctuating conscious level for 6 hours or more
|
Position |
Comment |
|
Paed |
I agree with the statement as it stands but find this confusing - if we are saying that acyclovir will be started if the cause of diminished consciousness is not known then this statement is superfluous. It suggests one might be looking for a cause of prolonged seizures which is distinct from the cause of the diminished consciousness. Surely life isn’t that complicated ! If the only purpose of incliding the stamtent is to add acyclovir I personally would leave this out. If its to make people consider the diagnosis and relevant additional tests then I can see the sense in leaving it in. Needs clarification |
|
neuro s |
? Too much – 2 out of 3 enough |
|
Paed ED |
I don’t think you should specify the number of events as one by itself can be indicative, so I would go with the first lot of statements |
|
Virology |
A few thoughts before attempting
to complete the questionnaire. It has been pointed out that HSVE
is extremely rare and although it is a rare disease HSE is the commonest
non-epidemic (sporadic) viral encephalitis in industrialised countries. It may well be that the incidence is an under-estimate and some minor
cases may be unrecognised but still leave patients with residual
problems. The broad brush approach
is difficult because the clinical picture
differs among neonates and older persons, e.g. neonates do not have febrile
convulsions although many clinicians fail to appreciate this. It is possible that with the rise in
sexually transmitted diseases, more cases of neonatal
encephalitis will occur, mostly infected by HSV2. It is also important to appreciate that
there are not recommendations for treatment with aciclovir for
longer than 10 days, e.g. 14-21 days and with higher doses, e.g. 60 mg/kg
per day. A recent study showed that morbidity may be due to
intermittent reactivation of herpes simplex in the months, or even years, after
neonatal treatment. Comments have been made that the
rarity of HSE must be balanced against the cost of treatment. However, it must be born in mind that cases
in which have been demonstrated that there
was a delay in recognising HSE with subsequent and usually severe
brain damage, is very costly, usually of the order of about £1million or more.
For example, I have four large and multiple leverarch files for
neonatal HSE which have yet to be settled, although not occurred in the same
year. I have one or two for adults,
but usually two or three new cases are
sent to me each year. |
|
Neuro |
but have no evidence base |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
96% |
0% |
4% |