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Management of children and young people with an acute decrease in conscious level (RCPCH guideline update 2015)
  1. Sarah Reynolds1,
  2. Dilshad Marikar2,
  3. Damian Roland2
  1. 1 Department of Neonatal, John Radcliffe Hospital, Oxford, UK
  2. 2 Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Cardiovascular Sciences, University of Leicester, Leicester, UK
  1. Correspondence to Dr Dilshad Marikar, Paediatric Emergency Medicine Leicester Academic (PEMLA) group, Leicester Royal Infirmary, Infirmary Square, Leicester LE1 5WW, UK; dilshad.marikar{at}nhs.net

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About this guideline

This guideline provides an evidence and expert consensus-based framework to assess and manage paediatric patients aged 4 weeks–18 years with a decreased conscious level of unknown cause.1 It was produced by the Royal College of Paediatrics and Child Health (RCPCH) and is endorsed by the National Institute for Health and Care Excellence (NICE), Royal College of Nursing (RCN) and College of Emergency Medicine (CEM). It updates previous guidance produced in 20052 to reflect evidence of changes in the demographics of children presenting to emergency settings with a decreased conscious level.3

The guideline provides a general overview of management, and readers are directed to national guidelines for detailed management of specific conditions (see box 1 for resources examples).

The following patient groups are not included in this guideline:

  • neonates

  • preterm infants on neonatal intensive care units

  • children with a known medical condition which can cause decreased conscious level (eg, epilepsy), where an agreed management plan is in place for acute illness

  • children with a daily baseline score of Glasgow Coma score (GCS) of <14 (eg, children with epileptic encephalopathy or minimally responsive state following acquired brain injury).

Box 1

Resources

NICE guidelines

Other Guidelines

Key issues

Decreased conscious level is defined as being unresponsive, or responding only to voice or pain on the Alert, Voice, Pain, Unresponsive (AVPU) scale, or a GCS or modified GCS of ≤14 (box 2).

The differential diagnosis to consider within the first hour and key management points are shown in table 1.

Box 2

Scales for assessing consciousness

AVPU scale—decreased consciousness=V or less

  • A=alert; V=responds to voice; P=responds to pain; U=unresponsive

Glasgow Coma Score (GCS)

  • Eye: 4=open; 3=to command; 2=to pain; 1=no response

  • Motor: 6=obeys command; 5=localises; 4=flexion withdrawal; 3=abnormal flexion; 2=abnormal extension; 1=no response

  • Voice: 5=converses; 4=confused; 3=inappropriate words; 2=incomprehensible; 1=no response

Modified GCS: for children under 5 years or with developmental delay

  • Eye: 4=open; 3=to command; 2=to pain; 1=no response

  • Motor: 6=normal spontaneous movements; 5=localised to supraorbital pain or withdraws from touch; 4=withdraws from nail bed pain; 3=abnormal flexion in response to pain; 2=abnormal extension in response to pain; 1=no motor response

  • Voice: 5=orientated to sounds, interacts, normal vocalisation for patient; 4=cries but consolable, inappropriate interactions; 3=inconsistently inconsolable, moaning; 2=inconsolable, agitated; 1=no verbal response

Table 1

Differential diagnosis for decreased conscious level

History taking

The following should be ascertained, with the timing noted:

  • duration of symptoms

  • vomiting

  • headache

  • fever

  • convulsions

  • periods of fluctuating consciousness

  • trauma

  • ingestion of medications, alcohol or recreational drugs

  • presence of medications in the child’s home.

Observations and core investigations

  • Key observation parameters are specified in box 3.

  • Suggested core investigations for a child with a decreased conscious level are shown in box 4. If drug ingestion or overdose is suspected, consider saving a plasma sample for future toxicology analysis.

Box 3

Recommendations for observations and continuous monitoring

Consider measuring the following observations on first assessment and then hourly

  • Heart rate

  • Respiratory rate

  • Oxygen saturations

  • Blood pressure

  • Physical appearance/state

  • Temperature

Consider measuring the following continuously:

  • Oxygen saturations

  • Continuous cardiac monitoring (ECG leads)

Consider record conscious level using Alert, Voice, Pain, Unresponsive (AVPU) scale or Glasgow Coma Score (GCS):

  • Every 15 min if GCS is ≤12 or V on AVPU scale

  • Every 30 min if GCS is >12

  • A decrease in AVPU or GCS indicates the need for an urgent medical review

Box 4

Core investigations

  • Capillary and laboratory blood glucose

  • Blood gas

  • Full Blood Count (FBC), U&Es, Liver Function Tests(LFTs) + blood film

  • Plasma ammonia + lactate

  • Blood culture

    • *Serum save sample

  • Urinalysis

  • 10 mL of urine to be saved for later analysis (including urine toxicology)

Emergency assessment and management

A structured ABCD approach should be taken for a child with a decreased conscious level.

Airway and breathing

  • Consider intubation if GCS is <8 (or patient is unresponsive to pain on the AVPU), unless the child is showing signs of improvement.

  • Give 100% oxygen if oxygen saturations are ≤95%.

Circulation

Circulatory compromise should be considered if one or more of the following are present:

  • mottled, cool extremities

  • diminished peripheral pulses.

Consider circulatory shock if one or more of the following are present:

  • systolic blood pressure is less than fifth percentile for age

  • decreased urine output <1 mL/kg/hour

In children with decreased conscious level and shock, consider the following diagnoses:

  • sepsis

  • trauma

  • anaphylaxis

  • heart failure

The following factors should be considered in managing shock in a child with a decreased conscious level:

  • Children with evidence of trauma should be managed according to Advanced Paediatric Life Support (APLS) guidelines.

  • Administer a fluid bolus of 20 mL/kg of isotonic fluid unless ketoacidosis or raised intracranial pressure (ICP) is present; in these circumstances give 10 mL/kg of isotonic fluid.

  • Assess the response to the fluid bolus (eg, normalisation of tachycardia).

  • Consider administering fluid boluses of ≥60 mL/kg, as guided by clinical response.

  • Consider intubation and ventilation if >40 mL/kg of fluid bolus has been given, to prevent uncontrolled pulmonary oedema developing. Children who have not responded to a 40 mL/kg fluid bolus should be monitored in a high dependancy/intensive care setting.

  • Consider starting drug treatment to support the circulation and refer to paediatric intensive care if >40 mL/kg of fluid has been given with little clinical response.

Disability

  • Neurological status should be continually monitored and deterioration in conscious level requires urgent reassessment (box 2).

  • As part of a careful general examination, assess all children for evidence of trauma from a collapse and request core investigations to detect any underlying medical cause (see box 4).

  • The possibility of non-accidental injuries and safeguarding concerns should always be considered; use national guidance (see box 1) to assess for alerting features

Blood glucose

  • Measure capillary blood glucose (CBG) within 15 min of presentation

  • If capillary blood glucose is ≤3 mmol/L give 2 mL/kg of 10% dextrose intravenously and consider performing a hypoglycaemia screen (see box 5).

  • An infusion containing 10% dextrose may then be needed to maintain CBG between 4 and 7 mmol/L.

  • Consider seeking urgent support from an endocrinology or a metabolic specialist.

Box 5

Hypoglycaemia screen recommendations

If blood glucose is <3 mmol/L consider the following additional investigations:

  • Plasma insulin

  • Plasma cortisol

  • Plasma growth hormone

  • Plasma free fatty acids

  • Plasma beta-hydroxybutyrate (consider bedside ketone monitor)

  • Plasma acyl-carnitine profile (on blood spot card)

  • Urine organic acids

  • Plasma amino acids

Refer to the British Inherited Metabolic Disease Group Recurrent Hypoglycaemia Guideline for further information (see box 1)

Seizures

  • Perform a detailed history and examination in a child during the first hour of a child in postconvulsive state, and consider observation alone if capillary glucose is normal without performing any other tests. Reassess the child if they have not awoken from the postconvulsive state within 1 hour.

  • A child presenting a prolonged seizure (lasting >5 min) should be managed as per APLS and local status epilepticus guidelines (see box 1).

  • In addition to checking the CBG, check plasma calcium and magnesium levels.

  • If seizures continue despite anticonvulsant treatment consider discussing with a paediatric intensivist, especially if

    • plasma sodium level <125 mmol/L

    • ionised calcium level <0.75 mmol/L or plasma calcium level <1.7 mmol/L

    • plasma magnesium level <0.65 mmol/L.

Raised ICP

Signs of raised ICP are shown in box 6. If increased ICP is suspected:

  • request urgent cranial imaging and discuss with paediatric intensive care unit

  • consider sedation, intubation and ventilation before imaging to maintain a PaCo2 between 4.5 and 5 kPa

  • position the child’s head in the midline with 20 degree upwards tilt

  • avoid internal jugular central lines

  • give restricted isotonic fluids

  • consider giving mannitol or hypertonic saline.

Box 6

Signs of raised intracranial pressure

  • Pupillary dilation (unilateral or bilateral)

  • Pupillary reaction to light impaired or lost

  • Bradycardia (heart rate <60 beats/min)

  • Hypertension (mean blood pressure >95th centile for age)

  • Abnormal breathing pattern

  • Abnormal posture

When to perform lumbar puncture

  • A lumbar puncture(LP) should be performed when no acute contraindications exist (see box 7) for the following working diagnoses:

    • bacterial meningitis/sepsis

    • viral encephalitis

    • tuberculous meningitis

    • cause unknown.

  • A normal CT scan does not exclude raised ICP and should not influence the decision to perform LP if other contraindications are present.

  • The decision to perform a LP in a child with a decreased conscious level should be made by an experienced paediatrician or consultant with paediatric experience who has examined the child.

Box 7

Contraindications for lumbar puncture

  • Signs of raised intracranial pressure (ICP)

  • GCS of ≤8

  • Deteriorating Glasgow Coma Score (GCS)

  • Focal neurological signs

  • A convulsion lasting >10 min with a GCS of ≤12

  • Shock

  • Clinical evidence of systemic meningococcal disease

  • CT or MRI scan suggesting blockage or impairment of the cerebrospinal fluid pathways

  • Beware of performing lumbar puncture in children with abnormal clotting

  • A normal CT scan does not exclude raised ICP

Cranial imaging

Carry out an urgent cranial CT or MRI scan when the child is stable if the working diagnosis is

  • raised ICP

  • intracranial abscess

  • unknown cause of reduced GCS.

Consider performing a cranial MRI scan within 48 hours if the diagnosis is still uncertain

What to do if the cause is still unclear

Consider other causes:

  • deliberate harm/injury by others (safeguarding concerns)

  • overdose/accidental ingestion of a toxic substance

  • sedation/anaesthesia/analgesia

  • carbon monoxide

  • hashimoto encephalopathy.

Consider performing additional tests in discussion with a specialist after reviewing core investigations if the cause of decreased conscious level remains unknown (eg, electroencephalogram)

Critical appraisal

Many recommendations in this guideline are prefaced by the word ‘consider’, which is used to indicate that the recommendation is based on weak evidence, or on expert consensus; it could be argued that this will lead to variation in practice between hospitals, as the recommendations may be considered less as guidance and more as a reference book.

The full guideline has been summarised into a poster algorithm (see box 1). However, there are some discrepancies between the two which may lead to variation of practice:

  • This guideline directs readers to consider trauma, non-accidental injury and safeguarding concerns in a child with a decreased conscious level. These are not included as differentials in the summary poster.

  • The full guideline states that a child in a post-convulsive state with a normal blood sugar may be observed with careful assessment in the first hour, whereas the summary poster implies performing core investigations in all cases.

In addition to the history taking points specified in this guideline, a wider approach should be taken, including asking about history of foreign travel (eg, travel to malaria endemic areas would add cerebral malaria to the differential diagnosis), and enquiry into family and social factors including consanguinity, history of infant/family death, household composition (in consideration of non-accidental injury), and drug and alcohol use.

This guideline gives clear directions on indications and contraindications for lumbar puncture (LP), as well as the need to involve senior decision makers. In clinical practice, the timing of performing LPs in a child with a decreased conscious level may not always be straightforward. For example, a child presenting to a paediatric emergency department may not meet any contraindication criteria for LP stated in this guideline, but it may be judged safer to transfer care to the general paediatric ward for reassessment before a LP is performed. This decision may be influenced by factors including performance targets (eg, 4-hour wait), varying staff skill-mix and lack of confidence in performing the procedure. In our clinical practice, we note that some experienced paediatricians are wary of the face validity of safely performing an LP in a child presenting acutely with a decreased conscious level (eg, a child with a Glasgow Coma Score of 11) and no stated contraindications.

Carbon monoxide poisoning is discussed in the guideline as a potential cause for altered consciousness but not included in the poster. However, given that the Chief Medical and Nursing Officers warn that carbon monoxide poisoning is likely to be underdiagnosed and that children are at increased risk of death and neurological injury,4 there is a strong case for assessment and management of carbon monoxide poisoning being specifically addressed by including carbon monoxide blood levels as a core investigation.

What should I start doing

  • Look for signs of raised ICP in all children with a decreased conscious level; consider intubating and ventilating patients in this group before cranial imaging.

  • Perform core investigations (box 4) including a plasma ammonia level in all children with a decreased conscious level of uncertain cause.

  • Ensure that the decision to perform a LP in a child with a decreased conscious level is made by an experienced paediatrician or consultant who has also examined the child in conjunction with a review of available imaging.

  • Assess all patients for alcohol/drug intoxication—alcohol intoxication was identified as the most common cause of decreased consciousness for children aged >12 years in a national audit.3

  • Ensure there is adequate documentation of relevant history and examination. This will help with continuity of care and act as a medicolegal record—national audit has shown unsatisfactory documentation of history and assessment.3

What should I continue to do

  • Continue to consider non-accidental injury in all children presenting with a decreased consciousness level.

  • Take a careful and thorough history including family history and foreign travel.

  • Involve parents early and ensure they are informed of emergency and ongoing management.

  • Take a blood glucose level in all patients with a decreased conscious level and consider a hypoglycaemia screen when blood sugar is <3 mmol/L (box 4).

Clinical bottom Line

  • A child with a decreased conscious level is at increased risk of morbidity and mortality and should be managed as a paediatric emergency.

  • Non-accidental injury and safeguarding concerns should always be considered in this patient group.

  • A systematic ABCDE approach should be used for assessment which will guide management and core investigations performed.

  • Do not forget to assess for evidence of raised intracranial pressure.

References

View Abstract

Footnotes

  • Contributors DM and SR: initial manuscript draft. DM and DR: manuscript revisions.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Correction notice This paper has been amended since it was published Online First. The author order has been changed with Sarah Reynolds now being the first author.

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