PAEDIATRIC ALTERED CONSCIOUS LEVEL GUIDELINE

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CLINICAL QUESTIONS

 

 

The clinical questions to be answered by the guideline are due to be discussed at the next Guideline Development Group meeting in February 2004.

 

A draft list of the questions to be answered is published below.

To understand where the questions will fit into the final guideline view FLOW DIAGRAM

 

 

CLINICAL QUESTIONS

 

In children, which conscious level scores are validated and can be used to pick up altered conscious level and changes in conscious level?

 

In children with altered conscious level, what are the causes and the presenting features of those causes?

 

Can the presenting features of the different causes differentiate sub-groups of children who can be tested / treated differently?

History features including                      Headache

                                                            Vomiting

                                                            Fever

                                                            Seizures

Examination features including               Pulse

                                                            Pulse oximetry

Blood pressure

Neck stiffness

Fever

Seizures

 

In children with altered conscious level, which rapid tests will differentiate sub-groups of children who can be tested / treated differently? 

(“rapid” = result within 1 to 2 hours)

            List of “rapid bedside” tests:      Blood glucose

                                                            Blood gas

                                                            Urinalysis – ketones, leucocytes, blood

                                                            Urea and electrolytes and liver function test

                                                            Chest x-ray

                                                            Ammonia and lactate

CRP

FBC

Clotting screen

            Lumbar puncture – microscopy, glucose, protein

 

In children with altered conscious level, in which sub-groups should other tests be performed at the same time as the “rapid bedside” tests even though the results will not be back for some time and therefore won’t help in initial management?

(“bedside” = can be taken on ward / in ED)

            List of “delayed bedside” tests:  Viral studies

Serum PCR

Blood culture

Lumbar puncture –culture, PCR, glycine

Urine / serum amino acids

Urine organic acids

Urine orotic acid

                                                                        Uric acid

                                                                        Gal-1-PUT

                                                                        3-hydroxybutyrate and free fatty acids

                                                                        Save spun serum

                                                                        Save urine sample

                                                                        Thyroid function / antibodies

                                                                        Autoimmune screen

 

In children with alterted consciousness, when is lumbar puncture contraindicated?

 

In children with altered conscious level, in which sub-groups should special tests be undertaken

(ie tests which cannot be performed at the bedside by the admitting doctor)?

 

In children with altered conscious level, which special tests will differentiate sub-groups of children who can be treated differently?

                                    List:      EEG

                                                CT

                                                MRI

                                                Invasive blood pressure monitoring

Intracranial pressure monitoring

                                                Muscle biopsy,

                                                Skin fibroblasts

                                                Mitochondrial assay     

Liver biopsy

 

BEFORE THE RESULTS OF ALL RAPID BEDSIDE TESTS ARE AVAILABLE

In children with altered conscious level, treating with anticonvulsants will reduce morbidity in which sub-groups?

 

In children with altered conscious level, intubation will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, dextrose infusion will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, antibiotics will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, acyclovir will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level started on acyclovir, which sub-groups can the acyclovir be stopped before the results of viral studies are available?

 

In children with altered conscious level, fluid and inotropic support will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, bicarbonate will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, mannitol will reduce morbidity / mortality in which sub-groups?

 

AFTER THE RESULTS OF RAPID BEDSIDE INVESTIGATIONS ARE AVAILABLE

In children with altered conscious level and raised intracranial pressure, which treatments will reduce morbidity / mortality (and in which sub-groups)?

                                    List:      intracranial pressure monitoring

mannitol

                                                steroids

                                                phenobarbitone

                                                morphine

                                                thiopentone

ventilation

                                                hypothermia

                                                paralysis

                                                ventricular drainage valve

                                                subtemporal decompression

 

In children with altered conscious level, hyperglycaemia induction will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, keeping nil by mouth will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level and kept nil by mouth, which feeds can be reintroduced safely and when?

 

In children with altered conscious level, bicarbonate will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, dialysis will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, sodium benzoate / phenylacetate will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, biotin will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, vitamin B12 will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, pyridoxine will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, NTBC will reduce morbidity / mortality in which sub-groups?

 

In children with altered conscious level, vitamin cocktail (thiamine / riboflavin / coenzyme Q10 / ubiquinone) will reduce morbidity / mortality in which sub-groups?