Table 1

Differential diagnosis for decreased conscious level

DiagnosisKey points
ShockSee emergency management section—circulation
Raised intracranial pressureSee emergency management section—disability
Seizure
Post convulsion (post-ictal state)
Trauma
Sepsis Diagnosis: temperature >38°C or <35.5°C or tachycardia or tachypnoea or white cell count >12×109/L or <4×109/L or non-blanching rash
Investigations:

  • Chest X-ray

  • Urine culture

  • Blood PCR (meningococcus and pneumococcus)

  • Coagulation studies

  • Skin swab (inflamed areas)

  • Joint aspiration (if signs of septic arthritis)

  • Thick and thin film for malarial parasites (if foreign travel to endemic area)

Management: follow NICE sepsis guidelines (see box 1)
Acute hydrocephalusAs per RCPCH guidelines on childhood stroke (see box 1)
Stroke
Metabolic/endocrine Hypoglycaemia: see emergency management section (disability)Modified GCS: for children under 5 years or with developmental delay
Diabetic ketoacidosis: use DKA guideline (see box 1)
Hyperammonaemia:

  • Free flowing sample required (arterial or venous), transported on ice

Consider a level of >100 μmol/L as abnormal and seek expert metabolic advice
Intracranial infection Differential: meningitis (viral, bacterial or TB), intracranial abcess, HSE
Investigations: lumbar puncture if no contraindications (see box 6)
Management:

  • HSE: aciclovir (duration decided by local infectious diseases expert)

  • Meningitis (bacterial or TB): NICE guidelines (see box 1)

Intoxication/poisoning Diagnosis: alcohol intoxication was the most common cause of decreased consciousness identified for children >12 years old in the 2011 multisite audit.3
Investigations: consider blood alcohol test when considered as a cause of decreased conscious level
Management:

  • Manage according to APLS principles—beware of respiratory failure and aspiration

  • Treat hypoglycaemia

  • Consider all likely contributory drugs

Hypertension Investigations

  • Look for signs of raised intracranial pressure and papillodema

  • Perform four limb blood pressure

  • Perform urinalysis for blood/protein

  • Urea and Electrolytes (U+Es)

Management

  • Discuss with PICU/nephrology if decreased conscious level and blood pressure >95th centile for age

  • APLS, Advanced Paediatric Life Support; DKA, diabetic ketoacidosis; HSE, herpes simplex encephalitis; NICE, National Institute for Health and Care Excellence; PICU, paediatric intensive care unit; RCPCH, Royal College of Paediatrics and Child Health; TB, tuberculosis.