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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Summary analysis
Round one
Key – Statements in green obtained more than 75% agreement and accepted
Statements in blue there were significant comments
to suggest a change for the next round
Statements
in red and crossed out obtained less than 75% agreement and/or there
were significant comments to suggest they should not be part of the next round
1. Definition:
Children presenting to hospital
have a reduced conscious level if they score less than 15 on the modified
For assessing changes in conscious
level the modified
2. Observations:
Children with a reduced conscious
level should have the following observations made
*heart
rate
*respiratory
rate
*oxygen
saturation level
*blood
pressure
continuous
cardiac monitoring (ECG leads monitoring rhythm)
temperature
* recorded at least every hour
until the observations and clinical state are stable.
Changes in conscious level should
be observed by recording a modified
3. Capillary glucose
test:
Children with a reduced conscious level should have a capillary glucose tested within 15 minutes of presentation.
In a child 3 months of age or over
with reduced conscious level, a capillary glucose level of less than 3.5 mmol/l
is low and should be investigated further and corrected
In a child under 3 months of age
with a reduced conscious level, a capillary glucose level of < 2.6 mmol/l is
low and should be investigated further and corrected (see Metabolic illness
“Hypoglycaemia”).
In a child with reduced conscious
level, a capillary glucose level of 11.0 mmol/l or greater is high and should
be investigated further.
4. History of
illness:
In children with a reduced
conscious level, the following features should be elicited from the history:
vomiting
before or at presentation
headache
before or at presentation
fever
before or at presentation
convulsions
before or at presentation
alternating
periods of consciousness
trauma
ingestion
of medications or recreational drugs
presence
of any medications in the child’s home
consanguinity of parents
any previous infant deaths in the family
length
of symptoms
Non-accidental injury or other
child protection issues may be behind the cause of reduced consciousness in
children.
5. Airway assessment and protection:
Children with a reduced conscious level
are at risk of airway obstruction.
Children with a reduced conscious
level should be intubated if:
their
their
airway obstructs when it is not supported
they
have no cough (gag) reflex
they
look exhausted
they
have signs of raised intracranial pressure
they
are vomiting
their
oxygen saturations are less than 92% despite high flow oxygen therapy
there
are signs of shock
6. Breathing
assessment:
Children with a reduced conscious
level should be treated with high flow oxygen if their oxygen saturations are
less than 95%.
7. Identifying the
causes of reduced consciousness in children
The causes of reduced conscious
level in children which can be suspected and treatment initiated within the
first hour after presentation include:
shock
(hypovolaemic, distributive and cardiogenic)
sepsis
trauma
raised
intracranial pressure
intracranial
infection
metabolic
diseases
convulsions
Some children will be recovering from
a previous convulsion (post-convulsive state).
There may be a group of children
with reduced conscious level who have no specific clinical features to aid
diagnosis within the first hour of initial presentation.
In children with reduced
consciousness, concurrent management strategies need to be started to treat the
potential different causes, whilst waiting for test results to confirm the most
likely diagnosis.
Children with reduced conscious
level following a convulsion may be observed for 1 hour after the convulsion
has stopped without any tests or treatments, if the patient is stable or
improving
Core investigations:
All children with reduced
conscious level (except those patients within one hour post convulsion, who are
clinically stable) should be investigated with the following tests at
presentation:
capillary
glucose
laboratory
blood glucose
urea
and electrolytes (Na, K, Cr)
liver
function tests (Aspartate transaminase or alanine transaminase, alkaline
phosphatase, albumin or protein)
blood
gas (arterial or capillary or venous – pH, pCO2, HCO3-)
full
blood count (haemoglobin, white cell count and differential, and platelet
count) and film
blood
culture
1-2ml
of plasma to be separated, frozen and saved for later analysis if required
1
- 2 ml of plain serum to be saved for later analysis if required
urinalysis
for ketones, glucose, protein, nitrites and leucocytes
10ml
of urine to be saved for later analysis
Plasma ammonia (taken from a venous or arterial sample)
Plasma lactate
Plasma
amino acids
Coagulation
studies – activated partial thromboplastin time, prothrombin time,fibrinogen,
fibrinogen degredation products
C-reactive
protein
Blood
spot on Guthrie card
Urine for organic acids, amino acids and orotic acid
Urine
for culture
Throat
swab for bacterial culture
Cranial Computed Tomography scan
Cerebrospinal
fluid should be collected if there are no contraindications for lumbar puncture
As a non-sterile urine sample is
required for these tests, a urine bag should be in situ as soon as the patient
has had monitors attached.
If a urine sample has not been
collected within an hour of presentation, the patient should be catheterised
If no diagnosis is made after the
core investigations have been reviewed, further tests to request include:
urine
toxicology screen
thick
and thin blood film, if recent foreign travel
an
urgent electroencephalogram
MRI
(magnetic resonance imaging)
Cerebrospinal
fluid Ziehl-Nielsen staining for tuberculosis if the initial
microscopy is abnormal
Cerebrospinal
fluid lactate
Serology
for mycoplasma and other viruses
Thyroid
antibodies and thyroid function tests
Contraindications for lumbar
puncture include:
a deteriorating
focal
neurological signs
shock
clinical
evidence of systemic meningococcal disease
papillary
dilation (unilateral or bilateral)
papillary
reaction to light impaired or lost
bradycardia
(heart rate less than 60 beats per minute)
hypertension
(mean blood pressure above 95th centile for age)
abnormal
breathing pattern
an
abnormal doll’s eyes response (an abnormal response is random movement or no
movement relative to the eye socket on turning the head to the left or right,
or no upward gaze on flexing the neck)
an abnormal posture
signs
of raised intracranial pressure
a
a
focal seizure
a
seizure lasting more than 30 minutes
agitation
a
purpuric rash
A normal CT scan does not exclude
acute raised intracranial pressure and should not influence the decision to
perform a lumbar puncture if other contraindications are present.
The decision to perform a lumbar
puncture in a child with a reduced conscious level should be made by an
experienced paediatrician, who has examined the child.
8. Shock.
Recognition:
Shock can be recognised clinically
if one or more of the following signs are present in a child with reduced
conscious level:
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Capillary refill time > 2
seconds |
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Mottled cool extremities |
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Diminished peripheral
pulses |
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Systolic blood pressure is less
than 5th percentile for age |
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Decreased urine output
<1ml/kg/hour |
If shock is present in a child
with reduced consciousness, look for signs of:
sepsis
trauma
(blood loss, tension pneumothorax, cardiac tamponade)
anaphylaxis
(urticarial rash, wheeze, stridor, swollen lips/tongue)
heart
failure (enlarged liver, peripheral oedema, distended neck veins, heart murmur)
Shock in a child with a reduced
conscious level is not a diagnosis in itself and so the core investigations
should be requested to determine the cause.
Treatment:
If shock is present in a child
with a reduced conscious level, a fluid bolus of 20 ml per kg of either
crystalloid or colloid should be given.
The response to a fluid bolus
should be monitored by heart rate, capillary refill time, urine output and
level of consciousness.
A positive response to a fluid
bolus can be defined as a reduction in tachycardia, a reduction in a prolonged capillary
refill time, an increase in urine output and an improvement in the level of
consciousness.
Further fluid therapy should be
guided by clinical response.
Fluid boluses of up to and over 60
ml per kg may be required, guided by clinical response.
If more than 40 ml per kg has
been given, the child should be intubated and ventilated to prevent
uncontrolled pulmonary oedema developing
If more than 40 ml per kg has
been given with little clinical response, inotropic support should be initiated
Children with a reduced conscious
level and shock which has been unresponsive to 40 ml per kg should be monitored
on an intensive care unit.
9. Sepsis
Recognition:
Sepsis can be defined as the
systemic response to infection.
In a child with a reduced conscious
level, sepsis should be suspected and treated if two or more of the following
are present:
a
body temperature of >38 C or <36 C or history of fever at home
tachycardia
tachypnoea
a
change in white cell count to >12000 cu mm or <4000 cu mm
or if there is a non-blanching
petechial or purpuric skin rash.
A child with a reduced conscious
level and suspected sepsis could have another underlying diagnosis and should
have the core investigations requested.
Treatment:
In a child with a reduced conscious
level and suspected sepsis, braod spectrum antibiotics should be started
intravenously after appropriate cultures have been taken.
In a child with a reduced
conscious level and suspected sepsis, microbiological advice should be sought
for second line antibiotics if there is a poor response to treatment.
A child with a reduced conscious
level and suspected sepsis should be reviewed by an experienced paediatrician
within the first hour of presentation.
A referral to a paediatric
intensive care unit should be considered within the first hour of presentation
in a child with a reduced conscious level and suspected sepsis
10. Trauma
Recognition:
In a child with reduced conscious
level, evidence of trauma should be elicited from the history and examination.
In a child with reduced
consciousness and evidence of trauma from a collapse, the core investigations
should be requested to detect an underlying medical cause in the child.
Treatment
A child with reduced conscious
level and evidence of trauma should be further managed according to Advanced
Paediatric Life Support and the NICE Head injury guidelines.
11. Raised
intracranial pressure
Recognition
Intracranial pressure is related
to cerebral perfusion pressure by the following equation:
Cerebral
perfusion pressure = mean arterial pressure – intracranial pressure
Raised intracranial pressure can
be defined clinically by the presence of 2 or more of the following signs:
Reduced
conscious level (being Unrousable or GCS < 9)
Abnormal
pattern of respiration (hyperventilation, irregular ventilation or apnoeas)
Abnormal
pupils (unilateral or bilateral dilated pupils or unreactive pupils)
Abnormal
posture (decorticate or decerebrate posture or complete flaccidity)
Abnormal
doll’s eye (oculocephalic) response or caloric (oculovestibular) response
Ensure the results of all the core
investigations performed are reviewed, and consider further tests if the cause
of the raised intracranial pressure is not diagnosed.
Treatment
If raised intracranial pressure is
suspected, then the child should undergo the following treatments:
Position
the patient’s head in the midline
Angle
the patient head up at 20 degrees above the horizontal
Maintenance
fluids should not be hypotonic
Sedate,
intubate and ventilate the patient to maintain the PaCO2 between 4.0
and 5.0 kPa
the
patient should be paralysed with muscle relaxing agents
Administer a dose of 1g / kg of intravenous mannitol
Administer
a dose of 5ml / kg of 3% sodium chloride (“hypertonic saline”)
Maintenance fluid should be administered at 100% of normal
Maintenance
fluid should be administered at 70% of normal
Maintenance
fluids should be 0.9% saline (with 20 – 40mmol/l potassium if required)
initially
Monitoring:
Arrange for patient transfer to a
paediatric intensive care unit.
Patients with suspected raised
intracranial pressure should have invasive intracranial pressure monitoring
performed if:
the
patient does not improve after initial intracranial pressure lowering measures have
been implemented
the
patient has cerebral oedema on CT scan
the
patient is hypertensive (a mean arterial pressure above the 95th
centile for age)
the
patient has a raised plasma ammonia level
In the acute setting, the most appropriate
method of monitoring intracranial pressure is by inserting :
an
intraventricular catheter
a subarachnoid screw or bolt
an
epidural
sensor
In the acute setting, the choice
of intracranial pressure monitoring device should be determined by the
neurosurgeon performing the procedure
Patients with an intracranial
pressure monitoring device in situ must also have invasive blood pressure
monitoring to calculate the cerebral perfusion pressure
Cerebral perfusion pressure
should be maintained above 60 mmHg with the PaCO2 in the normal
range
To maintain an adequate cerebral
perfusion pressure :
inotropic
support may be required
further
doses of mannitol may be used
further
doses of 3% saline may be used
hypothermia
should ideally be used in a controlled clinical trial setting only
deep
barbiturate sedation should ideally be used in a controlled clinical trial
setting only
subtemporal
decompression should ideally be used in a controlled clinical trial setting
only
12. Intracranial
infections
Bacterial meningitis:
Recognition:
Bacterial meningitis can be
diagnosed in the presence of at least one of the following:
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Diagnosis of bacterial meningitis |
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Cerebral spinal fluid (CSF)
positive bacterial culture |
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CSF positive Gram's stain with
negative cultures in the presence of clinical manifestations of meningitis. |
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Positive bacterial culture or
Gram's stain from blood, petechial lesion or sputum in the presence of
clinical manifestations of meningitis |
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Polymerase chain reaction
result positive for bacteria in the CSF or blood in the presence of clinical
manifestations of meningitis |
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CSF profile demonstrating
significant cytochemical changes such as white blood cells > 1,000/mm3,
neutrophils > 60%, protein > 100 mg/dL and glucose < 50 mg/dL in the
presence of clinical manifestations of meningitis |
Bacterial meningitis should be
suspected in children who score 8 or more in the following clinical decision
rule:
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Instructions Sum the scores of the symptoms/signs
present. If the total is 8 or more then the chances of having bacterial
meningitis is high. |
Symptom/sign Score If GCS < 9 = 8 Neck stiffness present = 7.5 Duration of symptoms =1 /each 24 hrs Vomiting = 2 Cyanosis =
6.5 Petechiae = 4 Serum CRP = CRP
value (g/dl) divided by
10 |
Treatment
If bacterial meningitis is
suspected, dexamethasone 0.4mg / kg should be administered before or with the
first dose of antibiotics
If bacterial meningitis is
suspected, broad spectrum antibiotics should be started without waiting for a
lumbar puncture to be performed if it is contraindicated
If bacterial meningitis is
suspected, broad spectrum antibiotics should be continued until further advice
is available from microbiology
Herpes simplex encephalitis:
Recognition:
Herpes simplex encephalitis (HSE)
can be diagnosed by the presence of at least one of the following
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Diagnosis of HSE |
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A positive PCR for herpes
simplex virus DNA from a cerebrospinal fluid sample |
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Specific herpes simplex virus
antibody production in a cerebrospinal fluid sample |
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Herpes simplex virus from a
brain biopsy sample |
HSE should be suspected clinically
in a child with reduced conscious level if two or more of the following are
present:
Fever in the history or a temperature > 38C on admission
Seizures
(either focal or generalised)
Headache
in the history or on admission
Vomiting
in the history or on admission
Focal
neurological signs
Treatment:
If HSE is suspected clinically
then intravenous aciclovir 10mg / kg (or 500mg/m2 if aged 3 months
to 12 years) twice a day should be administered, without waiting to perform a
lumbar puncture if a lumbar puncture is contraindicated
If HSE is confirmed or highly
suspected then intravenous aciclovir should continue for 14 days
Intravenous aciclovir can be
stopped if the cerebrospinal fluid sample results are negative for either PCR
or HSV specific antibody
Intravenous aciclovir can be
stopped if a magnetic resonance image performed 3 days after presentation is
normal
Intracranial abscess
Recognition:
An intracranial abscess can be
diagnosed from the results of cranial imaging.
Treatment:
If an intracranial abscess is
diagnosed, broad spectrum antibiotics should be administered after blood
cultures have been taken
If an intracranial abscess is
diagnosed, advice from a paediatric neurosurgeon should be obtained urgently
Tuberculous meningitis
Recognition:
Tuberculous (TB) meningitis can be
diagnosed from a cerebrospinal fluid sample by a positive TB culture or a
positive PCR for TB DNA.
If the microscopy of a
cerebrospinal fluid sample is abnormal, request a Zeihl-Neelsen stain
If the microscopy of a
cerebrospinal fluid sample is abnormal, request a PCR for TB DNA.
If the microscopy of a
cerebrospinal fluid sample is abnormal seek urgent advice from the microbiology
department
13. Metabolic illness
Hyperglycaemia
Diabetic ketoacidosis can be
diagnosed if all three of the following are present in a child with reduced
consciousness:
A
capillary or venous blood glucose of 11.0 mmol/l or more
A
capillary or venous blood pH of less than 7.3
Ketones
in the urine
If diabetic ketoacidosis is
diagnosed, then follow the NICE guidelines on the management of type 1
diabetes.
Hypoglycaemia
Hypoglycaemia in a child with an
altered conscious level requires the following investigations to be taken
during the hypoglycaemia episode:
plasma
lactate
plasma
ammonia
plasma
insulin
plasma
cortisol
plasma
growth hormone
plasma
free fatty acids
plasma
beta-hydroxybutyrate
urine
organic acids
acyl carnitine profile (on Guthrie card or from stored
frozen plasma)
galactose-1-phosphate
uridyl transferase level
urine
orotic acid
urine
amino acids profile
urinary
non-glucose reducing substances
Treatment
The emergency treatment of
hypoglycaemia in a child with a reduced conscious level is a bolus of 5 ml/kg
of 10% dextrose solution
An infusion of 10% dextrose
solution should be administered to maintain the blood glucose between 4 and 7
mmol/l
Hypoglycaemia is not a diagnosis
in itself, therefore urgent support from an endocrinologist and metabolic
medicine physician should be obtained to determine the subsequent management
Hyperammonaemia
A plasma ammonia level of 200
micromol/l is significantly raised and needs actively treating
If the plasma ammonia level is
above 200 micromol/l, then the following investigations need to be sent and
reviewed:
blood
gas
plasma
amino acids profile
urinary
amino acids profile
urinary
organic acids profile
urinary
orotic acid
liver
function tests - aspartate transaminase/alanine transaminase, alkaline phosphatase,
albumin/protein
Coagulation
studies – activated partial thromboplastin time, prothrombin time, fibrinogen,
fibrinogen degredation products
Treatment
A plasma ammonia level of 200
micromol/l needs actively reducing by starting a sodium benzoate infusion
Sodium benzoate should be given
with a loading dose of 250 mg/kg (diluted in 15ml/kg of 10% dextrose) over 90
minutes
After the loading dose, a further
infusion of sodium benzoate 250 mg/kg (diluted in 15ml/kg of 10% dextrose)
should be administered over 24 hours
A plasma ammonia level of 200
micromol/l needs actively reducing by starting a sodium phenylbutyrate infusion
of 500 mg / kg (diluted in 25 ml/kg of 10% dextrose) administered over 24 hours
A plasma ammonia level above 200
micromol/l for six hours despite treatment requires emergency haemodialysis
A plasma ammonia level above 500
micromol/l requires emergency haemodialysis and transfer should be arranged
urgently, whilst starting the ammonia reducing treatments available locally
As soon as a plasma ammonia level
of 200 micromol/l or above is detected, contact the nearest metabolic medicine
centre for advice
As soon as a plasma ammonia level
of 200 micromol/l or above is detected, contact the nearest paediatric dialysis
centre and arrange transfer for potential haemodialysis, whilst starting the
ammonia reducing treatments available locally
Catabolic state
A child with a reduced conscious
level, a capillary/venous pH < 7.3 and with ketones in the urine is in a
catabolic state.
Any child in a catabolic state not
caused by diabetic ketoacidosis should have the following investigations
requested:
plasma
lactate
plasma
ammonium
plasma
amino acids
liver
function tests - aspartate transaminase/alanine transaminase, alkaline phosphatase,
albumin/protein
urinary
amino acids profile
urinary
organic acids profile
For any child in a catabolic state
not caused by diabetic ketoacidosis, advice should be obtained urgently from
the nearest metabolic medicine unit
A child with a reduced conscious
level who is in a catabolic state needs treating by following the algorithm
below:
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Children in a catabolic state are at
risk of raised intracranial pressure, therefore careful monitoring is required
with the large fluid volume administration.
Lactate levels need to be
carefully monitored during 10% dextrose infusion
If lactate levels rise above 15
mmol/l obtain urgent advice from the nearest metabolic medicine unit
If lactate levels are
persistently high despite treatment for hypoxia and shock discuss with the
nearest metabolic unit the need for an urgent skin and muscle biopsy
A child in a catabolic state will
need nutrition restarted early to prevent further catabolism
A child in a catabolic state will
need dietetic input on the first day of admission
14. Prolonged
convulsion
A convulsion needs treating if it
has not stopped after 10 minutes.
The treatment of a prolonged
convulsion (i.e. lasting longer than 10 minutes) should follow the A.P.L.S.
guidance (Advanced Paediatric Life Support).
If the convulsion is prolonged
(i.e. lasting longer than 10 minutes) and the child is not known to have epilepsy,
then the core investigations should be sent at presentation.
If the convulsion is prolonged
(i.e. lasting longer than 10 minutes) and the child is under a year old, then
plasma calcium and magnesium should be requested as well as the core investigations
at presentation.
If a child has had a convulsion
lasting more than 10 minutes a lumbar puncture is contraindicated for at least
the following 24 hours after the convulsion has stopped
If the plasma sodium is less than
125 mmol/l and the convulsion is ongoing, an infusion of 3% saline (5 ml/kg)
should be given over one hour
If the ionized calcium is less
than 0.75 mmol/l and the convulsion is ongoing, an infusion of 0.3ml/kg of 10%
calcium gluconate should be given over 5 minutes
If the plasma calcium is less than
1.7 mmol/l and the convulsion is ongoing, an infusion of 0.3ml/kg of 10%
calcium gluconate should be given over 5 minutes
If the serum magnesium is less than
0.75 mmol/L and the convulsion is ongoing, an infusion of magnesium sulphate 50mg/kg
should be given over 10 minutes
15. Post-convulsion
state
After a convulsion has stopped, a
child will often have a period of reduced consciousness, the “post-convulsion
state”
The post convulsion state will
last for less than one hour in the majority of children
During the first hour of the
post-convulsion state, a detailed history and examination should be performed
During the first hour of the
post-convulsion state, it may be appropriate to observe the child without any tests
or treatments being sent
After the first hour of the
post-convulsion state, if the child has not recovered normal consciousness the
core investigations should be performed
16. No clinical clues
to the cause
A child with a reduced conscious
level and no obvious clinical signs pointing towards the cause should have the
core investigations and further tests sent
A child with a reduced
consciousness and no obvious clinical signs pointing towards the cause should
have supportive treatments implemented to protect their airway, breathing and
circulation
A child with a reduced
consciousness and no obvious clinical signs pointing towards the cause should
be started on broad spectrum antibiotics
A child with a reduced
consciousness and no obvious clinical signs pointing towards the cause should
be started on acyclovir.
A child with a reduced
consciousness and no obvious clinical signs pointing towards the cause should
be treated for non-convulsive status epilepticus if an urgent EEG is not
obtainable
If there is no obvious cause for
the child’s reduced conscious level discuss the case with a paediatric
neurologist within 6 hours of admission
17. Good practice points
During resuscitation and initial
management of a child with a reduced conscious level, the parents / guardians
should be allowed to stay with the child if they wish
During resuscitation and initial
management of a child with a reduced conscious level, the parents / guardians
should be kept informed of the possible underlying diagnoses and treatments
required
During resuscitation and initial
management of a child with a reduced conscious level, the parents / guardians
should be kept informed of the possible prognosis of their child if it is known
18. Peri-arrest
management
If a child with a decreased
conscious level deteriorates rapidly or dies suddenly, the parents / guardians
should be asked to consent for a skin biopsy
If a child with a decreased
conscious level deteriorates rapidly or dies suddenly, a urine sample should be
collected by catheter or suprapubic aspiration
If a child with a decreased
conscious level dies without a diagnosis being made, the coroner needs to be
informed and a post-mortem examination should be performed by a paediatric
pathologist within 24 hours of death
If a child with a decreased
conscious level dies without a diagnosis being made, a pathologist should
perform the following:
At the time of post mortem:
Full skeletal survey, X-rays to
be reported by a radiologist with expertise in NAI
Snap freeze a small sample
(about 1cc) of heart, kidney, liver and muscle in liquid nitrogen
Take samples of blood and bile
on Guthrie cards
Take a sample of skin in
tissue culture medium
Take
a sample of urine from the bladder or renal pelvis
Take specimens for virology
and microbiology
Take standard samples of all
organs for histology
Retain the brain for
neuropathological examination
After the post
mortem
Document virology and micribiology
results
Perform an oil red O stain on
frozen sections of heart, kidney, liver, and muscle and examine for
microvesicular fat
Blood and bile to Chemical Pathology for mass
spectrometry for acylcarnitine and fatty
acid oxidation
Urine
to Chemical pathology for organic and orotic acid assay
Skin to Enzymology for
cultured fibroblasts and storage in liquid nitrogen
Report on paraffin sections of
samples for histology
Neuropathological
examination of the brain after a week and samples taken for microscopy. (The brain
can then be returned to the body in time for the funeral).