Paediatric Acute care Guidelines PMH Emergency Department

Background

  • The unconscious and unresponsive child is a very serious and potentially life threatening situation.
  • The key to treatment is quick stabilisation and treatment of life threats, then careful but quick evaluation of the cause and treatment of reversible causes.
  • Any child with a VP shunt with decreased conscious state should be assumed to have a shunt blockage and raised intracranial pressure until proven otherwise.
  • Senior emergency doctor or specialist (e.g. ICU or anaesthetics) help is usually warranted and should be considered early.

Common Causes of Unconsciousness

  • Trauma
  • Sepsis
  • Seizures/post ictal
  • Ingestion 
  • Endocrine and Electrolyte abnormalities

Assessment 

Assessment of conscious level

  • Two scales which are readily assessable and recordable are the:
    • AVPU
      • A – Alert/Awake
      • V – Repsonds to voice
      • P – Responds to painful stimuli
      • U – Unresponsive/Unconscious
    • Glasgow Coma Scale GCS (modified for children)

Modified Glascow Coma Scale

    < 1 year   1-4 years  > 5 years

Eyes
Open    

4 Spontaneous
 To speech and touch  
 To pain  
 No response  

Best
Verbal Response     

 5 Normal vocal sounds, cries, periods of quiet wakefulness Alert – word or phrases of usual ability Orientated, appropriate words and phrases to usual ability
Spontaneous irritable cries Less than usual words, spontaneous irritable cry Confused/disorientated
Cries to pain only  Cries or vocal sounds to pain only Inappropriate words
Moan, grimace/facial movement to central pain  Occasional whimper or moan to pain Incomprehensible sounds
No response  No response No response 
Best
Motor Response      
6 Moves spontaneously and purposefully Obeys commands/usual movements  Obeys commands/usual movements 
Localises to stimuli Localises to painful stimulus Localises to painful stimulus
Withdraws in response to pain Withdraws in response to pain Withdraws in response to pain
Responds to pain with abnormal extension Abnormal flexion Abnormal flexion
Responds to pain with abnormal extension Abnormal extension Abnormal extension 
No response No response No response

History

Key points to obtain:

  • Past history , particularly the presence of Ventriculo-peritoneal (VP) shunt 
  • Recent injuries, especially head injuries
  • Progress of unconsciousness – sudden or slowly progressive deterioration 
  • Fever
  • Headaches (and onset of headaches – abrupt or progressive)
  • Neck stiffness
  • Vomiting
  • Medications that might have been accessible
Investigations

Investigations and blood tests are likely to be needed unless diagnosis is absolutely clear

Consider:

  • Glucose (Don’t Ever Forget Glucose) 
  • Blood Gas (arterial or venous)
  • FBC 
  • UEC
  • Calcium 
  • Blood cultures (if febrile or sepsis is considered a possibility)
  • CT head – likely to be needed, but make decision in consultation with senior clinician
  • EEG – rarely needed as an acute investigation, but consider in non-convulsive status (in consultation with neurology)
  • Blood alcohol level and drug screen 

Management 

Any patient who scores a P in the AVPU or < 9 on the Glascow Coma Scale requires airway support. 

Resuscitation
  • Airway + C-Spine Immobilisation 
    • Assess adequacy and ensure there is no obstruction
    • Have a low threshold for early intubation
  • Breathing
    • Support with oxygen and assisted ventilation if needed
    • Beware of hypoventilation and rising CO2 – causes raised intracranial pressure
  • Circulation
    •  Assess for signs of shock (slow capillary refill, hypotension) and treat appropriately 
  • Disability 
    • Rapid neurological assessment
    • If seizures occurring or non-convulsive status thought likely refer to Status Epilepticus
  • Glucose
    • Early evaluation of BGL
    • Collect growth hormone/cortisol/insulin levels if glucose is low
  • Seek the cause of  the coma
Potential Causes
Trauma
  • Accidental or non accidental
Hypoxic-ischaemic injury
  • Cardiorespiratory arrest, shock syndromes, near-drowning, smoke inhalation
Intracranial Infection
  • Meningitis, Encephalitis, Post-infectious
Mass Lesion
  • Haematoma, Abscess, Tumour
Fluid, Electolytes, Acid-base
  • Hypernatraemia, Hyponatramia, Acidosis/Alkalosis
Epilepsy Disorders
Systemic Infection
  • Sepsis syndrome, Septic encephalopathy
 Complications of Malignancy
 Poisoning
 Acute Ventricular Obstruction
Vascular  
  • Arteriovenous malformations, Embolism, Venous thrombosis, Arteritis Homocysteineuria
Hypertensive Encephalopathy 
Endocrine Dysfunction
  • Hypoglycaemia
  • Diabetes mellitus
  • Diabetes insipidus
Respiratory Failure
Renal Failure
Hepatic Encephalopathy
Reye’s Syndrome
Inherited Metabolic Disorders
  • Lactic acidosis
  • Urea cycle disorder
  • Aminoacidopathies
Hypothermia, Hyperthermia
Iatrogenic 
  • Overcorrection of acidosis
  • Overhydration
  • Drug overdose

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