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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Summary analysis
Round one and two
and three
1. Definition
Children presenting
to hospital have a reduced conscious level if they score less than 15 on the
modified Glasgow coma score or they are only responsive to voice, pain or are
unresponsive on the AVPU score.
Attempts to fully
rouse a sleeping child should be made before recording the assessment of
conscious level
For assessing changes
in conscious level the modified
2. Observations
Children with a
reduced conscious level should have the following observations recorded at
presentation: heart rate
respiratory rate
oxygen saturation level
blood pressure
temperature
Children with a
reduced conscious level should have the following observations recorded at
least every hour until the observations and clinical state are stable:
heart rate
respiratory
rate
oxygen
saturation level
blood
pressure
Children with a
reduced conscious level should have the following monitored continuously from
presentation until the monitoring and clinical state are stable:
heart rate
oxygen
saturation level
continuous
cardiac monitoring (ECG leads monitoring rhythm)
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 children 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 children with a
reduced conscious level, a capillary glucose of 2.6 – 3.5 mmol/l is borderline
low and the result of the laboratory glucose (requested with the core
investigations) should be reviewed urgently.
(In children with a reduced conscious level and a
borderline low glucose, the time to repeat the capillary glucose test and the
decision to investigate and treat borderline low hypoglycaemia needs to be agreed
at a local level)
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
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.
Intubation
Children with a
reduced conscious level should be considered for intubation if:
their
their
their airway obstructs when it is
not supported
their airway is compromised by
vomiting
their respiratory rate is inadequate
for oxygenation or ventilation
they look exhausted
they have signs of raised
intracranial pressure
their oxygen saturations are less than 92% despite high flow oxygen
therapy
and airway opening
manoeuvres
they have signs of shock despite
resuscitating with fluid boluses
totalling 40 ml / kg or
more
6. Breathing
assessment
Children with a reduced
conscious level are at risk of respiratory depression
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
(see “Working diagnoses” below)
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.
Core investigations:
All children with
reduced conscious level (except those patients within one hour post convulsion,
who are clinically stable and have a normal capillary glucose, and those
patients involved in trauma not related to a medical collapse) 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-)
Plasma ammonia (taken from a venous
or arterial sample)
full blood count and film
(haemoglobin, white cell
count and differential, and platelet count)
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
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.
Lumbar puncture:
A lumbar puncture
should be performed, when no acute contraindications exist, if the clinical
working diagnosis is:
Sepsis / Bacterial meningitis
Herpes simplex encephalitis
Tuberculous meningitis
Cause unknown
Cerebrospinal fluid
should be analysed initially for Microscopy, Gram staining, Culture and
sensitivity, Glucose, Protein, PCR for herpes simplex and other viruses
However, a lumbar
puncture should be deferred or not performed as part of the initial acute
management in a child who has:
a
a deteriorating
focal neurological signs
had a seizure lasting more than 10
minutes and has a GCS less than or equal to 12
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 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.
Cranial imaging
A cranial CT scan
should be considered when the patient is stable if the working diagnosis is:
Raised intracranial pressure
Intracranial abscess
Cause unknown
Working Diagnoses
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:
|
Capillary refill
time > 2 seconds |
|
Mottled cool
extremities |
|
Diminished
peripheral pulses |
|
Systolic blood
pressure is less than 5th percentile for age |
|
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, intubation and ventilation should be considered to
prevent uncontrolled pulmonary oedema developing
If more than 40 ml
per kg has been given with little clinical response, drug treatment to support
the circulation should be considered.
Children with a
reduced conscious level and shock which has been unresponsive to 40 ml per kg
should be monitored on an intensive care or high dependency 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.
A child with a
clinical diagnosis of sepsis should be considered for the following additional
investigations:
chest X-ray
throat swab
urine culture, if urinalysis positive
for leucocytes and / or nitrites
lumbar puncture
PCR from blood for meningococcus and
pneumococcus
Coagulation studies (activated
partial thromboplastin time, prothrombin time, fibrinogen, fibrinogen
degradation products) if clotting abnormality suspected
skin swab, if areas of inflammation
are present
joint aspiration, if signs of septic
arthritis are present
a thick and thin film for malarial
parasites if foreign travel to endemic area
intracranial imaging, if no other
source of infection determined
Treatment:
In a child with a
reduced conscious level and suspected sepsis, broad 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.
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 suspected 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
A child with a
reduced conscious level and suspected raised intracranial pressure should have
the core investigations requested and should be considered for a cranial CT
scan when the patient is stable.
Ensure the results of
all the investigations performed are reviewed and consider further tests (see “Cause
unknown”) if the cause of the raised intracranial pressure is not diagnosed.
Treatment
Children with a
clinical diagnosis of raised intracranial pressure should have the following
treatments to prevent coning:
Position the patient’s head in the
midline
Angle the patient head up at 20
degrees above the horizontal
Sedate, intubate and ventilate the
patient to maintain the PaCO2 between 4.0 and 4.5 kPa
Maintenance fluids should not be hypotonic
(The
rate of maintenance fluids needs to be agreed at a local level)
(The
dose of mannitol needs to be agreed at a local level)
Monitoring
Arrange for patient
transfer to a paediatric intensive care unit.
12. Intracranial infections
a. Bacterial meningitis:
Recognition:
Bacterial meningitis
should be suspected in children with neck pain / stiffness who score 8 or more
in the following clinical decision rule:
|
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
100 |
Children with
bacterial meningitis do not always present with neck stiffness.
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
A child with a
reduced conscious level and suspected bacterial meningitis should have the core
investigations requested and should have a lumbar puncture if no acute
contraindications exist
Treatment
If bacterial
meningitis is suspected, dexamethasone 0.15 mg / 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
b. Herpes simplex encephalitis:
Recognition:
HSE should be
suspected clinically in a child with reduced conscious level if
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
or
the child has or has been in contact with herpetic lesions
The clinical
suspicion of herpes simplex encephalitis can be strengthened by:
a magnetic resonance image scan with
non-specific features of herpes simplex encephalitis
an abnormal EEG with non-specific
features of herpes simplex encephalitis
a positive CSF result for herpes
simplex virus DNA in PCR of CSF
Treatment:
If HSE is suspected
clinically then intravenous aciclovir 10mg / kg (or 500mg/m2 if aged
3 months to 12 years) three times 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 acyclovir
can be stopped before 14 days of treatment if there is no ongoing clinical
suspicion of herpes simplex encephalitis
c. Intracranial abscess
Recognition:
An intracranial
abscess should be suspected in a child with a reduced conscious level if:
there are focal neurological signs
+/- clinical signs of sepsis
there are signs of raised
intracranial pressure
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
d. Tuberculous meningitis
Recognition:
Tuberculous
meningitis should be suspected in a child with reduced conscious level if
there are clinical features of
meningitis
there has been contact with a case
of pulmonary tuberculosis
A child with a
reduced conscious level and suspected tuberculous meningitis should have the
core investigations requested and should have a lumbar puncture if no acute
contraindications exist
If the microscopy of
a cerebrospinal fluid sample is abnormal seek urgent advice from the
microbiology department
Tuberculous (TB)
meningitis can be diagnosed from a cerebrospinal fluid sample by a positive TB
culture or a positive PCR for TB DNA.
13. Metabolic illness
a. 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
b. Hypoglycaemia
A child with a
reduced conscious level and a laboratory glucose of < 2.6 mmol/l should have
the following tests requested from the saved samples, which were taken with the
core investigations:
plasma lactate
plasma insulin
plasma cortisol
plasma growth hormone
plasma free fatty acids
plasma beta-hydroxybutyrate
acyl-carnitine profile (on Guthrie
card or from stored frozen plasma)
urine organic acids
(The investigation
and treatment of children with a reduced conscious level and a capillary
glucose between 2.6 to 3.5 mmol/l needs to be agreed at a local level)
Treatment
The emergency
treatment of hypoglycaemia in a child 4 weeks old or less is an intravenous
bolus of 2ml/kg of 10% dextrose
The emergency
treatment of hypoglycaemia in a child more than 4 weeks old is an intravenous
bolus of 5ml/kg of 10% dextrose.
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
c. Hyperammonaemia
A plasma ammonia
level of 200 micromol/l is significantly raised and needs actively treating
A child with a
reduced conscious level and a plasma ammonia level of > 200 micromol/l,
should have the following tests requested from the saved samples, which were
taken with the core investigations:
plasma amino acids profile
urinary amino acids profile
urinary organic acids profile
urinary orotic acid
Coagulation studies – activated
partial thromboplastin time, prothrombin time, fibrinogen, fibrinogen
degredation products
As soon as a plasma
ammonia level of 200 micromol/l or above is detected, contact the nearest
metabolic medicine centre for advice
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
If the plasma ammonia
remains between 200 and 500mmol/l and has not improved with the sodium benzoate
infusion after 6 hours, the child should be considered for 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
d. Non-hyperglycaemic ketoacidosis
Non-hyperglycaemic
ketoacidosis is present in a child with a reduced conscious level, a normal or
low capillary/blood glucose, a capillary/venous pH < 7.3 and ketones in the
urine
A child with a
reduced conscious level and non-hyperglycaemic ketoacidosis, should have the
following tests requested from the saved samples, which were taken with the
core investigations:
plasma lactate
plasma amino acids
urinary amino acids profile
urinary organic acids profile
For any child with
non-hyperglycaemic ketoacidosis, advice should be obtained urgently from the
nearest metabolic medicine unit
If lactate levels
rise above 15 mmol/l obtain urgent advice from the nearest metabolic medicine
unit
Children with
non-hyperglycaemic ketoacidosis are at risk of raised intracranial pressure,
therefore careful monitoring is required with fluid balance.
A child with non-hyperglycaemic
ketoacidosis will need nutrition restarted early to prevent further catabolism
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 the plasma sodium
is less than 115 mmol/l and the convulsion is ongoing despite anticonvulsant
treatment, an infusion of 5ml/kg of 3% saline should be given over one hour
If the ionized
calcium is less than 0.75 mmol/l or 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 plasma
magnesium is less than 0.65 mmol/l and the convulsion is ongoing, an infusion
of magnesium sulphate 50mg/kg should be given over one hour.
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-convulsive state, it may be appropriate to closely observe a child,
whose capillary glucose is normal, without performing any further tests or
treatments
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
The following
additional tests should be requested if, after reviewing the core
investigations’ results, the cause of a child’s reduced conscious level remains
unknown:
CT scan
a lumbar puncture (if no acute
contraindications exist)
urine toxicology screen
urine organic acids
plasma lactate
In a child with a
reduced conscious level with an unknown cause after reviewing the core
investigations, CT scan and initial CSF results, the following tests should be
considered:
an EEG, organised as soon as
possible, to exclude non-convulsive status epilepticus
urine amino acids, in children less
than 5 years old
acyl-carnitine profile (on Guthrie
card or from stored frozen plasma)
ESR and autoimmune screen, to
exclude cerebral vasculitidis
Thyroid function test and thyroid
antibodies, to exclude Hashimoto’s encephalitis
Treatment
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 and intravenous aciclovir
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).