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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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Scope Module 1
Which patients should
be included in module one of the guideline?
Included in the
guideline will be any paediatric patient presenting with or developing
an altered conscious level of unknown cause.
Which patients should
be excluded from module one of the guideline?
Excluded from the guideline will be those infants presenting
immediately after birth and having not yet been discharged from hospital. This
excludes infants with neonatal encephalopathy, which encompasses a large number
of causes beyond the scope of the guideline.
Also excluded are patients above the age limit for admission
to the local paediatric department.
Patients who are being treated for a known cause of their
altered conscious level will be excluded from the guideline. This exclusion
criteria has been included to filter off some of the causes of altered
conscious level which are secondary to traumatic brain injury (e.g. obvious
signs of head injury) or systemic illnesses where altered consciousness may be
the end stage (e.g. airway obstruction, severe pneumonia, hypovolaemic shock).
Providing evidence-based management guidelines for all these causes where
altered consciousness is not primarily neurological in origin would create an
unusable document in terms of size. However, advice will be included at the
beginning of the guideline as to what these causes may be, how they could be
picked up in the “Advanced Paediatric Life Support” primary survey and where
guidance may be found (e.g. NICE guidelines CG24 “Head injury”). This advice
should also address the need to re-examine the guideline if by treating an
“obvious” cause the clinical course or recovery is atypical (e.g. a head injury
secondary to a fall may have been precipitated due to a primary
encephalopathy).
The exact nature
of the filtering process for those patients whose altered conscious level is
not primarily neurological in origin has not yet been determined.
There has been a discussion about whether other symptoms or
signs should be included as part of the entry criteria (e.g. focal neurological
signs, seizures, altered behaviour) to ensure that the early stages of
encephalopathies (altered consciousness due to a primary brain dysfunction) are
not missed. However, in a problem-based guideline only one problem or
presenting symptom / sign can form the entry criteria. If more than one symptom
is included then the guideline becomes unmanageable (as each individual problem
would need its own guideline) and it becomes more like a diagnosis-based
guideline (the summation of features forms a diagnosis at the beginning of the
guideline).
The definition of altered consciousness has been left open
for the time being until the systematic literature search / formal consensus
process has taken place.
What is the starting
point for module one of the guideline?
The guideline begins with the recognition that a paediatric
patient has attended hospital with an altered conscious level or that a child
already in hospital is recognised to develop an altered conscious level.
What are the end
points for module one of the guideline?
The guideline will end when first line investigations have
been sent, or are requested, and initial treatments have been started within
the first hour or so after presentation. Within the first hour very few
laboratory results will be back and the treatment options will be limited. The
treatment options available for first line staff include anticonvulsants,
intubation and ventilation, dextrose infusion, antibiotics, acyclovir, fluid
and inotropic support, bicarbonate, and mannitol. More complicated treatments
are unlikely to be available within the first hour after presentation, or would
not be started until further test results are reviewed (again unlikely to be
available within the first hour or so).
Further management decisions will therefore be covered in
the second module after further test results are available and second line
investigations have been considered.