Guideline for the management of a child aged 0‐18 years ......Analysis Round 1(part 1) Round 1...

Guideline for the management of

a child aged 0‐18 years with a

decreased conscious level

Appendix H

Contains;

‐ Delphi results

Royal College of Paediatrics and Child Health

5‐11 Theobalds Road, London, WC1X 8SH

The Royal College of Paediatrics and Child Health (RCPCH) is a registered charity in England and Wales (1057744)

and in Scotland (SC038299).

The management of children and young people with an acute decrease in conscious level (2015 Update) - Appendix H

2

Delphi results

Contents Delphi rules Panel response Analysis Round 1(part 1) Round 1 (part 2) Round 2 Round 3

Delphi Rules In this Delphi analysis, results have been combined as follows: Strongly disagree: 1, 2, 3 Neither agree nor disagree: 4, 5, 6 Strongly agree: 7, 8, 9 Consensus is considered to be achieved if 75% of the panellists strongly agree with the statement.

Panel Response Round 1 (part 1) Round 1 (part 2) Round 2 Round 3 Response rate

50.4% 47.5% 69.8%, 31.4

Comments underrepresentation from general paediatricians and metabolic clinicians in particular

underrepresentation from metabolic clinicians in particular

under representation from metabolic clinicians in particular

underrepresentation of nursing in particular

Emergency 15 16 13 11 General paediatrics 6 8

7 5

Intensive 10 12 6 6 Metabolic 6 4 1 6 Neurology 16 19 10 8 Nursing 10 8 7 2 Total 63 67 44 38

Each statement and the panel responses are presented graphically below along with any comments from the panel.


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Round 1 (part 1)

Observations 1. Changes in conscious level should be observed and recorded by a Glasgow Coma

Score/modified Glasgow Coma Score (GCS):

a. At presentation with reduced consciousness Consensus achieved: strongly agree 97%

b. Every 15 minutes if GCS less than or equal to 12 Consensus achieved: strongly agree 90%

c. Every hour if GCS greater than 12 No consensus achieved: strongly agree 67%

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d. A decrease in GCS indicates urgent medical review Consensus achieved: strongly agree 94%

2. Comments – [add note to explain these are verbatim comments – possibly move to page 1] Speciality Comment Manchester paediatric intensive care advanced nurse practitioners

In my area GCS difficult to assess following sedation

Paediatric neurologist if child has chronic encephalopathy with a GCS <12 I don’t think we need to record GCS every 15 min

Nursing GCS should be recorded half hourly if above 12 and less than 15 Paediatric neurologist Frequency depends on whether the child is stable or unstable. Paediatric intensivist Emphasis on recording should be made. GCS review frequency may also

depend on degree of fluctuations observed within above intervals, e.g. a fluctuating GCS may need more frequent review than hourly even if >12

General Paediatrics Sometimes a recorded decrease in GCS by 1 point is simply because the child is asleep. Other than this, I agree with the statement.

Nursing The decrease should be specified- 1-2 points or 2 or more points Emergency medicine Decrease of how much or any Paediatric neurologist Q2 I agree 15 mins at presentation of the patient or before diagnosis but

after 6 hours could review q3 as for q2 above definition of "urgent”?? I'd agree with urgent call e.g. for sudden drop to 9 or less but "soon" review when score falls from 13 to 12 or 11.

Paediatric intensivist Must also include set of basic of observations Paediatric neurologist If only recently changed to 13 -would recommend more frequent

monitoring in first few hours Paediatric intensivist frequency will depend on time course so 15 mins appropriate for initial

period of assessment but if GCS remains low for hours / days it would not be appropriate.

Emergency medicine If GCS 12-14 I would prefer GCS every 30min Metabolic The trend is also important so for patients with a fluctuating GCS, you

may not want to automatically go to hourly because of one level above 12

Emergency medicine cut off would 15mins GCS should be less than or equal to 13 (rather than 12 as listed)

Nursing It is possible that a GCS of 13 or 14 could require more frequent monitoring than hourly dependant on the cause of the decreased score

Emergency medicine If the child's conscious level has been stable for a period of time it would be permissible to alter the frequency of repeated observation following discussion between the medical and nursing team. Urgent medical review is usually predicated on a change in level of two points or more to account for variability in assessment.

Intensivist depends on the clinical situation

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Speciality Comment Paediatric intensivist/neurologist

I would state "at least" every....

Emergency medicine ? obs should be every 30 mins if GCS <14 Nursing It depends how much the conscious level has reduced by and how you

define urgent. Nursing A GCS of 12-15, at times would have closer observation than hourly, for

example a child with a head injury, nice guidelines will be followed for the recording of neuro observations

Paediatric neurologist AVPU is easier to use in non-traumatic decreased loss of consciousness at time of presentation

Paediatric neurologist It's worth splitting apart the components of the GCS. It's easier to visualise what constitutes a person with score of less than or equal to 12 that way.

Emergency medicine If GCS <15/15 then GCS should be recorded 15 or 30minutely Paediatric neurologist I would add: the GCS is only part of the clinical evaluation as it does not

mention R v L changes nor changes in pupillary size/response, hence GCS within 'neuro-obs' is what would be required. Also dictating the frequency of evaluation would determine a lot on the history, overall clinical examination and degree of concern/ diagnosis etc. Hence it is hard to be prescriptive. Would suggest: GCS as part of neuro-obs which would include above and BP/HR/RR etc.

Paediatric intensivist Descriptive terms should supplement the GCS Neurologist

might need to insert a comment that changing GCS also means need to check it more often - shift from 15 to 12 would need watching closely

Paediatric intensivist Every hour if the GCS is 12-15 is INADEQUATE Paediatric neurologist You have to get the balance right at night between letting the child sleep

and poking and prodding to assess GCS Neurologist

I would favour every 30 mins if GCS reduced but above 12 for the first 2 hours and hourly afterwards if stable

Paediatric intensivist The time frame for reviewing the GCS in a patient with a GCS > 12 will depend on the cause.

Paediatric intensivist

Depends on how quickly the GCS is changing and how long it has been at that level.

Paediatric intensivist GCS less than 9 will invariably need urgent medical intervention Changing GCS more important than number for how often to record. Need to record more frequently if changing as opposed to stable

Capillary Glucose Test 3. Children with a reduced conscious level should have a capillary glucose test at presentation.

Consensus achieved: strongly agree 98%

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4. Comments: Speciality Comment Paediatric neurologist BM as well as lab glucose General paediatrics Or venous blood, if access is to be immediately obtained - but avoids

delay. Emergency medicine is a rapid venous gas an acceptable alternative Paediatric neurologist correlate with plasma glucose as well Paediatric Intensivist better still a lab blood glucose ? Basic simple test which is easily corrected if positive Emergency medicine Mandatory! Paediatric neurologist This should be followed by plasma glucose estimation. Paediatric neurologist This is often done within the blood gas. May need rephrasing as:'... also

need a blood or capillary glucose done at presentation' Paediatric neurologist followed up by venous glucose

5. 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. Consensus achieved: strongly agree 90%

6. 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. No consensus achieved: strongly agree 68%

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7. In children with a reduced conscious level: A capillary glucose level of <3.0 mmol/l is low and should be investigated further and corrected. No consensus achieved: strongly agree 60%

8. In children with a reduced conscious level: A capillary glucose of 3.0 – 3.5 mmol/l is borderline

low and the result of the laboratory glucose (requested with the core investigations) should be reviewed urgently. No consensus achieved: strongly agree 44%

9. In children with a reduced conscious level: A capillary glucose level of <3.6 mmol/l is low and

should be investigated further and corrected (refer to hypoglycaemia guideline). No consensus achieved: strongly agree 27%

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10. In children with a reduced conscious level: A borderline low glucose, the time to repeat the capillary glucose test and the decision to investigate and treat borderline low glucose needs to be agreed at a local level. No consensus achieved: strongly agree 39%

11. Comments Speciality Comment Paediatrics I think this process should result in a recommendation re repeating the

glucose. Seems pointless to leave it out. The child with reduced conscious level is symptomatic and the threshold is higher than an asymptomatic child for example

Manchester paediatric intensive care advanced nurse practitioners

I would assume <3.0 is low, 3 - 3.5 borderline low

Nursing A glucose less than 4.0 would be considered low and a decision regarding treatment would be decided

Paediatric intensivist There is a small positive bias in capillary blood glucose compared to laboratory measurements. This has been taken into account in the levels set in 4-6. Levels in subsequent questions is likely to lead to more children being investigated

Paediatric intensivist Actions may vary depending on age of child and clinical presentation. Emergency medicine Too complex: each statement requires a decision on the definition of

low/borderline and investigation and treatment. What does investigation mean i.e. look for the cause of hypo screen with ammonia on ice etc.

Neurologist This is one area for prescriptive national guidelines Paediatric neurologist this isn't really in my area hence reason to agree locally Nursing Glucose of 3 or below should be investigated and treated in a patient

with reduced conscious level. 3-3.5 is borderline low and urgent glucose should be requested. Age of the child should be taken into consideration

Paediatric neurologist helpful to have guidelines for this although also need good documentation about any local decisions made

Paediatric Intensivist Normal' BG depends on age so even a level <2.6 may be normal in an infant. Evidence is now contested that a level <2.6 will be enough to cause neuroglycopenia

Paediatric neurologist the RCPCH guidelines should be followed Nursing The phrasing of questions 4-8 is ambiguous. Re. question 9 - guidance

should be national wherever possible to avoid discrepancies in management.

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Speciality Comment Emergency medicine I am assuming that cap glucose means a bedside as opposed to a

laboratory test. We have undertaken considerable work on this subject over the years. The bedside testing technology is less reliable at low glucose levels so we use a cut off of 3.1 or less (we used a level of 3.5 previously before auditing the comparison with lab values and the number of normal metabolic screens undertaken at that level) at which level we would undertake a full metabolic screen plus obtain a laboratory glucose. At this point we would treat. If the laboratory glucose confirms hypoglycaemia the metabolic screen samples are sent for processing.

General paediatrics Q9 doesn't really make sense.... Paediatric Intensivist/neurologist

the above are not mutually exclusive comments

Emergency medicine I don't see why in question 9, any local variation is useful, or safe. Surely that is the point of a national/international guideline. The only question should be the accuracy of local lab/monitors.

Paediatric neurologist There should be standard national guidelines on low cap glucose levels. Will need evidence to change the values to <3.6 rather than <2.6. Using local guideline will lead to confusion for all especially trainees.

Emergency medicine BM <2.6 needs investigation and treatment. Borderline 2.6-3.5 needs formal glucose and consideration of treatment

Paediatric neurologist Whilst I am not a metabolic specialist, we often are involved in above discussions re further Ix and what is 'normal' in the circumstances. Above would depend on 1) age of child 2) presentation i.e. sepsis/infection etc. 3) other symptoms when relatively well. Hence difficult to be prescriptive; also little normative data for what is acceptable in illnesses as a metabolic stress response

Neurologist there should be a consensus nationally on what a low glucose level is and when to treat

Paediatric intensivist I think the borderline level glucose and treatment should be on the national guideline

Identifying the causes of reduced consciousness in children 12. The cause(s) of reduced conscious level in children which can be suspected and for which

treatment may be initiated with in the first hour after presentation include:

a. Shock (hypovolemic, distributive or cardiogenic) Consensus achieved: strongly agree 98%

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b. Sepsis Consensus achieved: strongly agree 98%

c. Trauma Consensus achieved: strongly agree 98%

d. Raised intracranial pressure Consensus achieved: strongly agree 95%

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e. Intracranial infection Consensus achieved: strongly agree 100%

f. Stroke Consensus achieved: strongly agree 79%

g. Acute hydrocephalus Consensus achieved: strongly agree 81%

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h. Metabolic diseases Consensus achieved: strongly agree 92%

i. Intoxication / poisoning Consensus achieved: strongly agree 94%

j. Recovering from a previous convulsion (post-convulsion / “post-ictal” state) Consensus achieved: strongly agree 76%

13. Comments Speciality Comment Paediatrics If there is a clear history of a convulsion/seizure and a thorough assessment does

not suggest an immediate cause requiring treatment, it would be reasonable to wait and observe in the first hour

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Speciality Comment Paediatrics neurology

the treatment of stroke is controversial in children- although is done in adults recovering from a convulsion- has no specific treatment


Decreased conscious level of any cause apart from post ictal is an emergency with potential for severe morbidity and mortality

Emergency medicine

Treatment within an hour of presentation for stroke may be desirable but is almost impossible from a practical point of view in terms of recognising problem and getting appropriate imaging.

Paediatric neurology

Do you mean may need treatment but may not i.e. supportive only??

Paediatric Intensivist

whilst agreeing that shock, sepsis or non-head trauma or even "post ictal" may cause reduced consciousness intracranial causes must be considered and investigated as appropriate

Paediatric neurologist

I would remove post - ictal state This probably needs a separate question as more complex how quickly one should get worried

Nursing it may take more than one hour to diagnose intracranial infection or acute hydrocephalus

Emergency medicine

Again, the phrasing is ambiguous. This should be 2 distinct questions to address (a) whether the cause should be suspected and (b) whether treatment could/should be initiated within the first hour.

Emergency medicine

Status epilepticus too


The conditions labelled as a score of 5 may take up to an hour to consider and exclude (or confirm) before treatment is initiated, although the diagnosis may be earlier.

Emergency medicine

Last is unclear - yes it may be a cause but this does not mean it requires treatment at that stage; however if persists >1hour or is associated with additional signs then it does need action.

Emergency medicine

I am unaware of the appropriate acute treatment of stroke in children but suspect it would take more than 1hr to diagnose and treat. Post-ictal children need no specific treatment. not all of the above can have treatment within first hour

Emergency medicine

Presuming observation is not considered treatment with regard to recovering from post-ictal state.


Initiation of treatment presumes urgent imaging has been done within the first hour to enable correct diagnosis and hence management. This is often delayed by availability of urgent scanner and is largely dependent on local resources. Stroke can often be diagnosed late as a result in children as well as new onset metabolic diseases (IEM) same for poisoning. Hence would need rephrasing to include imaging access for stroke/acute hydrocephalus/raised ICP.


Anticoagulants/antiplatelet agents should only be given following a CT or MRI in the context of stroke


Shock and sepsis can cause a low GCS but not commonly - i.e. I would not be happy to attribute coma simply to sepsis, other causes need excluding.


Not a very good question as it does not differentiate between treatment for the "pathology" and supportive treatment

Emergency medicine

There are two parts to the statement and, for (paediatric) stroke, hydrocephalus and post-ictal states there is not usually a specific treatment to be initiated within the first hour, however it is still important to suspect these as potential causes.

Neurologist for several of these there will be high index of clinical suspicion but urgent imaging required to direct treatment and may not be within 1 hour


For much need to initiate treatment in a much tighter time frame- sepsis for example should be recognised and fully managed within an hour- not initiated. Initiated should happen almost immediately


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Cranial imaging/Lumbar puncture 14. An urgent acute cranial CT or MRI scan should be carried out when the patient is stable if the

working diagnosis is:

a. Raised intracranial pressure Consensus achieved: strongly agree 94%

b. Intracranial abscess Consensus achieved: strongly agree 86%

c. Cause unknown Consensus achieved: strongly agree 83%

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15. A cranial MRI should be arranged if possible, if not already done at presentation, within 48 hours, if the diagnosis is still uncertain Consensus achieved: strongly agree 83%

16. A lumbar puncture should be deferred and not performed as part of the initial acute management

in a child who has:

a. A GCS equal to or less than 8/15 Consensus achieved: strongly agree 84%

b. A deteriorating GCS Consensus achieved: strongly agree 88%

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c. New focal neurological signs Consensus achieved: strongly agree 76%

d. Had a convulsion (seizure) lasting more than 10 minutes and has a GCS equal to or less than 12/15 Consensus achieved: strongly agree 81%

e. Shock Consensus achieved: strongly agree 81%

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f. Clinical evidence of systemic meningococcal disease Consensus achieved: strongly agree 81%

g. Dilated pupil (unilateral) Consensus achieved: strongly agree 87%

h. Dilated pupils (bilateral) Consensus achieved: strongly agree 75%

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i. Impaired or lost pupillary reaction to light Consensus achieved: strongly agree 81%

j. Bradycardia (heart rate less than 60 beats per minute) Consensus achieved: strongly agree 81%

k. Hypertension (mean blood pressure above 95th centile for age) Consensus achieved: strongly agree 78%

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l. Abnormal breathing pattern Consensus achieved: strongly agree 79%

m. An abnormal posture Consensus achieved: strongly agree 79%

n. Signs of raised intracranial pressure Consensus achieved: strongly agree 83%

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o. A CT or MRI scan suggesting blockage or impairment of the CSF pathways, e.g. by blood, pus, tumour, or coning. Consensus achieved: strongly agree 84%

p. A normal CT scan does not exclude dangerous acute raised intracranial pressure and should not influence the decision to perform a lumbar puncture if other contraindications are present. Consensus achieved: strongly agree 90%

17. Comments Speciality Comment Emergency medicine Cranial MR should be performed within 24 hours if already performed on

presentation. Q14 Shock and meningococcal disease would read better if there was also a GCS present e.g. <12

Paediatric Intensivist Personal experience of dealing with patients developing herniation syndromes with normal CT

Paediatric neurologist There may be a number of systemic reasons why LP is contraindicated. Paediatric Intensivist Decision to perform MRI may depend on CT findings and clinical evolution

over first 48 hours and thus deferred or moved forward. Emergency medicine Define urgent versus emergency, pulse rate of 60 in fit adolescent? Paediatric intensivist Delayed MRI question not relevant Paediatric neurologist As a neurologist I have a lower threshold for LP and the important thing is

not to defer it so long that it is not worth doing and the opportunity to confirm a diagnosis of meningitis is missed.

Paediatric neurologist Reports may not be done initially by radiologists with appropriate expertise and have seen missed sinus thrombosis etc.

Paediatric neurologist CT is used to help diagnose a specific cause of RICP e.g. abscess, tumour, stroke but it can still be normal in some scenarios with RICP e.g. meningitis and encephalitis. In these circumstances, clinical signs should be used

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Speciality Comment Emergency medicine Better phrasing of 15. The absence of raised ICP on features on CT does not

automatically indicate it is safe to perform an LP. All other potential clinical contraindications should each still be appraised prior to LP.

Emergency medicine LP is not needed since we can get PCR for Meningococcus, too often junior reg's dilly dally around delaying treatment due to wanting an LP

Emergency medicine An LP with increased ICP can sometimes be therapeutic. Paediatric neurologist A Normal CT brain excludes raised intracranial pressure in 60% of cases. Paediatric neurologist 1. A GCS of 8/15 would imply the child is intubated or ventilated if that is an

acute change to 8/15; if no contraindications and in the context of meningo encephalitis an LP may still be warranted once the patient is stable, even if ventilated. The GCS per se does NOT help the clinician regarding an LP; it is the evolution of the clinical picture (which may NOT be reflected by the GCS which could remain the same). All the others are in keeping with raised ICP and possibly coning hence are definite contra indications to LP. Re meningococcal disease: an ID opinion needs to be sought as at times if blood cultures sterile after antibiotics and child stable CSF may be needed. LP after a seizure: if child is stable and it was a focal seizure the possibility of Herpes encephalitis needs ruling out hence CSF would be needed, but again only after child is stable. The GCS again on its own does not help decide on this.

Paediatric intensivist MRI would be the only way to determine whether LP is safe or not. Unknown IN BIH a lumbar puncture is necessary for the diagnosis Paediatric Intensivist A lumbar puncture should probably never be performed acutely. There is

simply no need. I have seen plenty of harm but no good. Now PCR is available LP can be performed days later when no acute concerns re ICP etc.

Neurologist Imaging guides diagnosis not the safety to perform lumbar puncture Paediatric intensivist This is absolute!!!! Emergency medicine I'm surprised in looking at the above and having to make a definitive

statement that I am strongly against CT in any of the above, but that probably reflects my work in ED solely and an LP not now being a common investigation within ED.

18. A lumbar puncture should be performed, when no acute contraindications exist, if the clinical

working diagnosis is:

a. Sepsis/bacterial meningitis Consensus achieved: strongly agree 83%

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b. Viral encephalitis including herpes simplex Consensus achieved: strongly agree 84%

c. Tuberculous meningitis (TBM) Consensus achieved: strongly agree 83%

d. Cause unknown Consensus achieved: strongly agree 76%

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19. The decision to perform a lumbar puncture in a child with a reduced conscious level should be made by a paediatrician, who fulfils middle grade competencies, who has examined the child. No consensus achieved: strongly agree 68%

20. Comments Speciality Comment Paediatrics I would probably want it discussed with a consultant first. Paediatric intensivist

Laboratory information such as coagulation status and full blood count (platelet count included) should inform decision by middle grade doctor.


Paediatrician should read - a suitably qualified and experienced individual who is deemed competent at local level e.g. Advanced Practitioner

Paediatric neurologist they need to have had a CT scan and discuss with consultant first Paediatric intensivist A consultant should be involved in question 18 Paediatric intensivist needs discussion with a consultant Emergency medicine minimal requirement Paediatric neurologist

It does not have to be a middle grade, but ideally a middle grade should examine and assess first. The less senior doctor may still be competent to perform the procedure

Emergency medicine LP should not delay treatment Nursing

Re. question 18 - a Paediatric Advanced Nurse Practitioner could potentially be working at the same level as a paediatric middle grade doctor

Nursing This should be termed paediatric clinician, as non-medics can manage such patients in secondary care

Paediatric intensivist/neurologist

While this may be appropriate for many competent registrars overseen in a safe setting such as PICU this may be a bland dangerous statement; needs consultant advice or opinion.

Emergency medicine Q18 - in the emergency dept this decision should be made by the responsible consultant.

Emergency medicine

Question 17 should read "A lumbar puncture should be performed as part of the initial acute management, when no acute..."


The middle grade should ideally discuss any child with decreased level of consciousness with the consultant prior to the lumbar puncture

Emergency medicine Or Paediatric ED SPR or Consultant Paediatric neurologist

It would be advisable for the paediatrician to discuss with a senior paediatrician as this is what happens currently if in doubt. Also overall most junior and middle grade doctors are highly reluctant to perform LPs even when no clinical contraindications. This means often treating with no CSF having been sent to identify any organisms etc.

Unknown

Middle grade paediatrician now have little experience and have ticked the competency boxes does mean that they are competent

Paediatric intensivist Never perform an LP if any reduced conscious level.

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Speciality Comment Paediatric neurologist

LPs are still performed too infrequently or delayed by junior staff. There should be someone resident in hospital 24 hours a day confident to make these decisions


A consultant should make the decision to perform an LP in a child with a reduced level of consciousness.


It should always be made by a paediatric consultant and should almost never happen in a child over one in the acute stage


lumbar punctures should rarely (if ever) be performed in a child (previously normal) with a decreased level of consciousness- I believe this should be a consultant decision

21. Cerebrospinal fluid investigations should include:

a. Opening CSF pressure if possible Consensus achieved: strongly agree 77%

b. Microscopy Consensus achieved: strongly agree 94%

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c. Gram staining Consensus achieved: strongly agree 94%

d. Culture & sensitivity Consensus achieved: strongly agree 94%

e. Glucose (compared to Laboratory Plasma Glucose, taken just before Lumbar Puncture) Consensus achieved: strongly agree 94%

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f. Protein Consensus achieved: strongly agree 94%

g. Lactate No consensus achieved: strongly agree 70%

h. PCR for herpes simplex and other viruses (HSV1, HSV2, VZV, enteroviruses) Consensus achieved: strongly agree 81%

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i. Sample to store for possible future investigations No consensus achieved: strongly agree 73%

j. Culture of Mycobacterium tuberculosis when clinically suspected Consensus achieved: strongly agree 86%

22. Comments Speciality Comment Paediatrics

m\y not do all of these depending on the initial presentation and investigations. Likely to have these back before doing the lumbar puncture so will guide investigations.


I am not certain what difference and actual CSF pressure 'number' would make to management other than to know whether CSF drains under excess pressure or not


Viral studies do not need to be part of initial investigations of clear evidence of bacterial infection.


As a neurologist of course I would want these and a lactate as well.


TB is very rare. It is also hard to diagnose without a decent amount of CSF. A consultant should be involved in discussing the amount of CSF in these cases. Spare CSF should always be kept for a few days or longer if possible. I am a neurologist and we often ask for extra investigations on the first CSF

General Paediatrics Viral PCR does not need to be requested acutely-await biochemistry and MC&S


"Urgent... when the patient is stable" - this is confusing wording. Does bradycardia not also need to reflect age centiles? 17. Should be

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Speciality Comment considered 20. Opening pressure is imperative and every junior should learn how to do this and what to do if it is abnormal

Paediatric neurologist Plasma glucose MUST be taken before LP. "BM" is not acceptable in my opinion.


Re TBM in addition to culture, there are also PCR based assays for identifying TB as well as blood tests (interferon gamma release assays) that can be done to help with a difficult diagnosis.

Paediatric intensivist (applies to interval LP) Paediatric neurologist

Base on clinical assessment. Also, if initial CSF analysis gives the diagnosis, why waste money and resources on other tests

Neurologist lactate only if metabolic concerns Paediatric intensivist

Lactate is not indicated in all cases but if easily available at the time of LP (e.g. using a blood gas analyser out of hours when laboratory lactate measurement is not available) then should be recorded as may prove to be useful later and then the LP would not have to be repeated.

Paediatric intensivist lactate if cause unknown or metabolic condition suspected 23. Other Samples - If viral encephalitis is suspected, liaise with virology and microbiology

colleagues, as Investigations should also include:

a. Throat swab for enteroviruses No consensus achieved: strongly agree 63%

b. Rectal swab for enteroviruses No consensus achieved: strongly agree 51%

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c. Swab of any skin vesicles No consensus achieved: strongly agree 68%

d. Convalescent serum No consensus achieved: strongly agree 45%

e. HIV testing No consensus achieved, strongly agree 19%, neither agree nor disagree 30%

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f. EEG if epileptic seizures or periodic spasms are suspected No consensus achieved: strongly agree: 60%

24. Comments Speciality Comment Manchester paediatric intensive care advanced nurse practitioners

Would be advised by relevant teams


Liaise with ID colleagues to advise on further investigations


Access to investigations may be centre-dependant and local protocol should be agreed with ID/microbiology colleagues

General Paediatrics

Investigations such as HIV testing, in the acute testing is usually not undertaken in view of consent, however can be included subsequently after discussions with Microbiology team.


Is rectal swab better than stool sample the EEG question here is out of context and won't distinguish between different types of encephalitis? the indication for EEG is in regards to diagnosis/localisation of possible seizures


Don't really understand question If we liaise with expert colleagues then they will decide further investigations. If access to an opinion is difficult then guidance for this is important.

Paediatric intensivist PCR should be added Paediatric neurologist

HIV is still uncommon in children. A decision to do this test should be discussed with a consultant in neurology and or ID. An EEG is helpful if no cause has been identified following ID or autoimmune investigations but overall it is less helpful than these investigations

Emergency medicine We would always discuss with the on-call virologist. General Paediatrics

Should this state investigations MIGHT also include? HIV testing is not routine. I wouldn't ask a microbiologist for advice about when to do an EEG!


State that HIV testing should be considered This EEG statement is unclear! I would like to answer this specifically but what do you mean?

Emergency medicine I would consult ID and neurology re; this question Emergency medicine

EEG is a valid investigation but is not in the realm of the virologist or microbiologist and does not belong with the opening statement


Paediatric ID opinion to be also sought on above. The list would depend on presenting symptoms of child and history of travel/contact etc.

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Speciality Comment Emergency medicine

Should be guided by specific clinical concern and local microbiology advice rather than dictated by a guidelines


Should be guided by specific clinical concern and local microbiology advice rather than dictated by a guidelines

Managing the causes of reduced conscious level in children 25. In children with a reduced conscious level, concurrent management strategies need to be started

to treat the potential different causes, and keep the child safe, while waiting for test results to confirm the diagnosis. Consensus achieved: strongly agree 98%

26. Comments Speciality Comment Paediatric intensivist

History and Examination may streamline precise choices but the principle of starting treatment whilst awaiting results as outlined above is strong.


Of course do this need to be integrated into a care pathway?


Of course


Yes, but with some thought and in a sensible order. Our studies have shown that aciclovir is overused and then often stopped after a couple of doses. With consideration to the individual case, it may not have been needed at all.

Emergency medicine

Rephrase 24: It is not uncommon for the final diagnosis to be confirmed days to hours after initial presentation. Do not delay or withhold treatments over concerns re a lack of current absolute diagnosis and it is appropriate to initiate concurrent management strategies treating several potential causes whilst awaiting formal results of investigations.


This is currently what happens in practice even prior to LP: various antibacterial and antiviral agents are started, seizures are treated, any metabolic abnormalities (low or high sodium, low glucose etc.) are treated whilst simultaneously trying to obtain other Ix to clarify the underlying cause(s).

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Alcohol intoxication 27. The commonest cause of acute intoxication leading to a child or young person having a reduced

conscious level is excessive alcohol (ethanol) ingestion. Care should follow the usual ABCD system (as in APLS), and include the core investigations. Look especially for and treat:

a. Hypoglycaemia with IV glucose and maintain ace dextrose/saline


b. Respiratory failure and or aspiration pneumonia Consensus achieved: strongly agree 84%

c. Hypotension Consensus achieved: strongly agree 77%

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d. Other drugs ingested at the same time, e.g. opiates, or benzodiazepines, or paracetamol Consensus achieved: strongly agree 87%

e. Avoid emetics (in case of aspiration) Consensus achieved: strongly agree 75%

f. Consider haemodialysis if severe intoxication or worsening coma, hypotension, acidosis, or with pre-existing liver disease. No consensus achieved: strongly agree 59%

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g. Identify all likely substances or drugs that may be contributing and call your local regional poisons unit if in doubt about the best treatment. Consensus achieved: strongly agree 87%

28. Comments Speciality Comment Paediatrics I would avoid emetics in all situations unless specifically recommended by

poisons unit Manchester paediatric intensive care advanced nurse practitioners

I am not sure that haemodialysis would be used in acute situation but more CVVH/CVVHD/CVVHDF

General Paediatrics Liaison with a regional poisons unit for a DGH is likely to be via the local PICU

Emergency medicine

I usually give a fluid bolus (for an adolescent up to a litre of saline) not evidence based but similar to adult practice and appears to help sober up. Toxbase first port of call

Paediatric intensivist not appropriate to look for other drugs in every person with alcohol intoxication

Emergency medicine

Re 27: a greater emphasis in the new guideline should be made to consider & explore toxicology (from prescribed, illicit, legal highs, household chemicals etc.). Legal highs particularly important to directly explore. Also recommend in guideline to consider carbon monoxide specifically and use the HPA 'COMA' questions. Emphasize to also consider measuring methaemoglobin levels


Re-first line, needs direction to an appropriate guideline or this may go wrong.


Although I don't see these children when they come in, I think doing a forensic Toxicology screen and liaising with local poisons unit is extremely important.

Paediatric neurologist Although unable to comment agree with all of the above.

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No clinical clues to the cause 29. 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:

a. A cranial CT scan Consensus achieved: strongly agree 87%

b. A lumbar puncture (if no acute contraindications exist) Consensus achieved: strongly agree 84%

c. Plasma lactate Consensus achieved: strongly agree 87%

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d. Urine toxicology screen Consensus achieved: strongly agree 87%

e. Urine organic acids Consensus achieved: strongly agree 84%

f. Plasma amino acids Consensus achieved: strongly agree 86%

30. Comments Speciality Comment Paediatric neurologist NH3 and urea too Emergency medicine Cranial CT, lactate and urine toxicology should be part of the core

investigations Paediatric intensivist The need for detailed metabolic testing may be age and history-

dependant. Paediatric neurologist and CSF lactate if you are doing an LP Paediatric intensivist LP will not change management

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Speciality Comment Paediatric intensivist need to add plasma ammonia Metabolic

Urine toxicology should be collected from the outset - the first urine passed. Whether or not it is actually sent for analysis can wait until core investigations are reviewed.

Unknown Lactate usually part of blood gas assessment which usually is a part of the assessment of decreased consciousness. Amino acids to assess raised leucine- MSUD notoriously difficult to diagnose as metabolic upset may be relatively mild.

Metabolic early on also measure methaemoglobin and carboxyhaemoglobin levels Paediatric intensivist/neurologist

Presumably a CT has already been done hence the more appropriate question is whether to MRI - yes, agree to that.

Emergency medicine

An suggested age range may be appropriately associated with testing for urine organic acids and plasma amino acids

Paediatric neurologist MRI Brain is a better modality Metabolic

Ammonia should be added to this as well as focus sing what additional investigations with regional metabolic team.

Paediatric neurologist If possible MRI brain would be more appropriate than CT brain. Paediatric neurologist Ammonia should be included since the results come back much more

quickly than urine OA and AA Paediatric neurologist

Yes; the list could be longer depending on the actual presentation, age, any history of dev. delay etc. Rather than a CT scan which is unlikely to yield diagnostically useful info in such a case, a brain MRI scan should be considered instead. And referral or discussion with a specialist team/centre.

Neurologist blood gas, glucose Emergency medicine Metabolic screen depends on age/presentation etc. Neurologist favour MRI over CT Metabolic

Plasma ammonia should be measured with the core investigations at the outset, in all children presenting with a reduced level of consciousness. This would be more important than measurement of plasma lactate.


Do not do lumbar puncture acutely as will not change management. need to be clear that child is stable without evolving raised intracranial pressure first

31. 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:

a. An EEG, organised as soon as possible, to exclude non-convulsive status epilepticus Consensus achieved: strongly agree 77%

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b. Urine amino acids, in children less than 5 years old No consensus achieved: strongly agree 68%

c. Acyl-carnitine profile (on Guthrie card or from stored frozen plasma) No consensus achieved: strongly agree 67%

d. ESR and autoimmune screen, for cerebral vasculitidies No consensus achieved: strongly agree 54%

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e. Thyroid Function Tests and Thyroid Antibodies, for Hashimoto’s encephalitis No consensus achieved: strongly agree 61%

f. Carbon monoxide tests (blood carboxyhaemoglobin/haemoglobin should be <6%; use finger clip pulse-CO-oximeter monitor, not a normal pulse-oximeter which misreads CO-Hb as oxi-Hb) No consensus achieved: strongly agree 57%

g. Breath alcohol level No consensus achieved: strongly agree 27%, neither agree nor disagree 29%

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h. Blood alcohol level No consensus achieved: strongly agree 57%

32. Comments Speciality Comment Paediatrics It is helpful to have list of other things to consider. Manchester paediatric intensive care advanced nurse practitioners

Would have to liaise with colleagues to clarify which of the above investigations would be required

Emergency medicine

Carbon monoxide poisoning and blood alcohol levels should be considered much earlier in the investigation process as they are important treatable causes of low GCS.

Paediatric intensivist The importance of history and physical examination must be underscored in the decision for any additional testing.

General Paediatrics

In a DGH context, I would be discussing with tertiary paediatric neurology before considering most of these tests.

Nursing Blood and breath alcohol needs to be more age specific Paediatric neurologist

non convulsive status is extremely rare in a child with no previous history of epilepsy it rarely presents with reduced conscious level in a previously well child I wouldn't do tests for vasculitis unless these were indicated from the imaging or previous history e.g. history of systemic vasculitis Hashimotos is unlikely if there have been no seizures; I suppose TPOs worth doing if cheap. CO tests might depend on history/presentation but I think would be done in A&E.


Difficult question Very context specific Maybe rephrased as what would be part of extended encephalopathy screen

Paediatric neurologist Also suggest extend the antibody screen now and store serum for anti NMDA etc.

Paediatric intensivist you cannot protocolise all of this Metabolic

Urine amino acids probably less important and reliable than plasma quantitative amino acids - gradually being phased out of many IMD labs' routine screen [our lab does still perform, but the conditions this picks up over and above blood amino acid analysis are not so often associated with acute encephalopathy, especially in absence of hyperammonaemia. COHb should be routinely measurable by blood gas analysers


NCSE is very rare as a cause of coma in my experience. Certainly without having a diagnosis of an epileptic encephalopathy. Ordering an EEG should be discussed with a neurologist at this stage. Similarly, TFTs etc. And blood tests for cerebral vasculitidies are unlikely to help and can even be normal (in vasculitis at least). They should be discussed with a neurologist. It would be worth adding autoantibodies onto this list like NMDAR and VGKC. They are

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Speciality Comment more likely to be abnormal. However, it may be best to just add a store serum sample and discuss further tests with a neurologist

Metabolic

Plasma amino acids are quantitative and should be the diagnostic test of choice. Urine amino acids are only useful in secondary tubular dysfunction or transport disorders. There should be no particular change to this based on age of the patient.

Unknown Urine amino acids reflect renal threshold and so are not a good test for IMD's. Acylcarnitine indicated if hypoglycaemia. Wider tandem mass spec screen on same sample will help rapid diagnosis of other causes e.g. MSUD, organic acidaemias etc.

Emergency medicine

Carboxyhaemoglobin should be measured at initial presentation (is available on most blood gas analysers immediately now), consideration should not be delayed for after CT and CSF results. A comment should be added to warn clinicians of solely attributing dec LOC to alcohol excess.

General Paediatrics EEG may also be useful for suspected encephalitis (initial/acute LP results may be normal)


Urine amino acids - not aware of an age cut-off Acylcarnitine - can be taken fresh Re-CO - I thought gas machine carboxyHb was reliable?

Emergency medicine

Carbon monoxide levels should be checked in the acute phase. Not later. Breathe test alcohol of limited use. Serum alcohol more useful.

Emergency medicine

Carbon monoxide testing is readily available on blood gas and should be included with initial investigations

Paediatric neurologist blood alcohol better test Metabolic Urine organic acids should not be age limited Paediatric neurologist unsure about breath alcohol test being available Emergency medicine No blood alcohol measurement available in lab Paediatric neurologist

PLEASE ADD: - autoimmune encephalitis i.e. Anti NMDA receptor antibodies, anti-VGKC antibodies (serum and/or CSF)

Neurologist Alcohol testing should be earlier. Only do investigation for Hashimoto if EEG abnormal

Metabolic Plasma ammonia 33. Treatment: A child with a reduced conscious level and no obvious clinical signs pointing towards

the cause should have supportive treatments implemented to protect their airway, breathing and circulation. Consensus achieved: strongly agree 100%

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34. A child with a reduced conscious level and no obvious signs pointing towards the cause should be started on broad spectrum antibiotics and intravenous acyclovir. Consensus achieved: strongly agree 83%

35. 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. Consensus achieved: strongly agree 79%


Involvement of a paediatric neurologist may depend on site of presentation and access to this and other tertiary specialties

Emergency medicine

Paeds neurology 24/7??


35: You must be joking. I wouldn't be impressed to be woken at 2am for such a discussion even if providing 24hr cover. Better to have a locally agreed clinical pathway. If this is followed properly there is nothing a neurologist can do over the phone at 6 hours. A timely (12-24 hours) consultation, seeing the patient and discussing the imaging and EEG with neuroradiology etc. would be better.


See earlier comment about aciclovir. It can be delayed whilst other tests are performed in some patients rather than started too often. Antibiotics probably should be started if no cause is found as meningitis is much more common


33. Odd statement as applies to all not just 35. In the absence of EEG where there is normal examination, imaging and EEG consider treatment for non-convulsive status epilepticus.


There needs to availability of paediatric neurologist to do this. This can be achieved by having a good network within the catchment area.

Nursing 34 broad spectrum antibiotics should be commenced, not acyclovir in every case

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Q 34- rather than 'should', to consider starting on.... (in practice this is what happens) Q 35. Most Ix and imaging unlikely to have taken place within 6 hr of admission hence not sure why '6 hours'? Could this be left more open ended, if by 24 hr no cause has been found and child has not improved, to consider discussing with neurologist/ ID specialist, etc.

Resuscitation 37. 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. Consensus achieved: strongly agree 95%

38. During resuscitation and initial management of a child with a reduced conscious level, the

parents/guardians should be kept informed of:

a. The main possible underlying diagnoses Consensus achieved: strongly agree 94%

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b. The treatments their child requires Consensus achieved: strongly agree 98%

c. The possible prognosis for their child, if known Consensus achieved: strongly agree 87%


Prognosis should generally not be discussed during initial investigations but can be referred to if asked by emphasising the need for as much diagnostic and clinical information (initial and evolving) as possible prior to more detailed discussion.

Emergency medicine

CARE SPECULATING IF ANY SAFEGUARDING ISSUES!! Prognosis require a complete diagnosis which may not be apparent at resus /initial management


Theoretically I agree with 37 but I am not usually present in the acute situation so it should depend on individual circumstances

Paediatric intensivist too early to discuss prognosis unless there are signs of imminent danger


Parents should be asked if they want to stay though, not assume that they do. in case they are traumatised by the experience

Intensivist 37 - unless there is a safeguarding issue that makes this unadvisable General Paediatrics

As with any situation, whether the parents stay or not is at the discretion of the clinician leading e.g. probably best not to be present for a LP

Metabolic Time limitations must be considered in above Paediatric neurologist

Rarely is the discussion for prognosis discussed at the time of resuscitation unless child is very unwell


In my opinion, this is more appropriate to be done by a Middle Grade Doctor with expertise or a Consultant.

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Often prognosis will only become clearer once underlying diagnosis or etiology is identified/ confirmed. At presentation in general it would be difficult to be able to know re outcome.

Paediatric intensivist Prognosis is usually uncertain in these cases Paediatric neurologist

Ideally yes - but in the stress of the situation, it is far too easy to say the wrong thing or be misinterpreted. There should be a person not physically involved in resus who communicates with parents.

Neurologist Not to spend vast time on all the possible differentials.

Peri-arrest management 40. If a child with a decreased conscious level deteriorates rapidly or dies suddenly:

a. The parents/guardian should be asked to consent for a skin biopsy No consensus achieved: strongly agree 73%

b. A urine sample should be collected by catheter or suprapubic aspiration Consensus achieved: strongly agree 78%

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41. If a child with a decreased conscious level dies without a diagnosis being made the coroner needs to be informed. A post-mortem examination should be performed by a paediatric pathologist within 24 hours of death, and a pathologist should perform the following at the time of the post-mortem:

a. Full skeletal survey, x-rays to be reported by a radiologist with expertise in NA

No consensus achieved: strongly agree 59%

b. Snap freeze a small sample (about 1cc) each of heart, kidney, liver, and muscle in liquid nitrogen No consensus achieved: strongly agree 33%

c. Take samples of blood and bile and Gutherie cards No consensus achieved: strongly agree 43%

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d. Take a sample of skin in tissue culture medium No consensus achieved: strongly agree 49%

e. Take a sample of urine from the bladder or renal pelvis No consensus achieved: strongly agree 44%

f. Take specimens for virology and microbiology No consensus achieved: strongly agree 49%

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g. Take standard samples of all organs for histology No consensus achieved: strongly agree 40%

h. Retain the brain for neuropathological examination No consensus achieved: strongly agree 30%

42. After the post mortem the pathologist should:

a. Document virology and microbiology results, perform an oil red O stain on frozen sections of heart, kidney, liver and muscles and examine for microvesicular fat No consensus achieved: strongly agree 20%

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b. Blood and bile to chemical pathology for mass spectrometry for acylcarnitine and fatty acid oxidation defects No consensus achieved: strongly agree 29%

c. Urine to chemical pathology for organic and orotic acid assay No consensus achieved: strongly agree 30%

d. Skin to enzymology for cultured fibroblasts and storage in liquid nitrogen No consensus achieved: strongly agree 29%

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e. Report on paraffin sections of samples for histology No consensus achieved: strongly agree 29%

f. Neuropathological examination of the brain after a week and samples taken for microscopy. The brain can then, in most cases, be returned to the body in time for the funeral. No consensus achieved: strongly agree 19%

43. Comments Speciality Comment Paediatric neurologist A pathologist should answer these questions Metabolic

Snap freezing samples of no use for metabolic investigations due to autolysis unless within 30-60 mins post death. Bile acylcarnitines, in my opinion are better that nothing, but not that helpful. Retrieving newborn screening blood card may be more useful as agonal changes difficult to interpret.

Emergency medicine We would discuss with the coroner before taking skin samples, etc. General Paediatrics Skeletal Survey less relevant for older children Emergency medicine

These investigations are not in my area but all seem reasonable to establish the cause of death and for implications relating to parents and siblings

Paediatric neurologist Although I am not a Pathologist. I would agree with above. Emergency medicine Post death samples are only allowed once the Coroner has agreed this. Paediatric neurologist

Neuropath examination of the brain often takes a long time and hence the delay re funeral. Agree with all options in Q 42 although not my speciality.

Neurologist some of these would depend on the age and background history Paediatric neurologist I would be guessing what a comprehensive pm should involve.

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Round 1 (part 2)

Core investigations 1. All children with a reduced conscious level should undergo core investigations except those:

a. Within one hour post-convulsion, who are clinically stable and have normal capillary blood glucose No consensus achieved: strongly agree 64%

b. Patients involved in trauma not related to a medical collapse No consensus achieved: strongly agree 58%

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2. The core investigations for all other children with a reduced conscious level are:

a. Capillary Blood Glucose Consensus achieved: strongly agree 98%

b. Laboratory Plasma Glucose Consensus achieved: Strongly agree 91%

c. Plasma Liver Function Tests (Aspartate transaminase or alanine transaminase, alkaline phosphatase, albumin or protein) Consensus achieved: Strongly agree 88%

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d. Blood Gas (arterial or capillary or venous â€“ pH, pCO2, pCO, HCO3, BE (arterial or venous lactate) Consensus achieved: strongly agree 99%

e. Plasma Ammonia (a venous or arterial sample, sent directly to the lab) Consensus achieved: strongly agree 84%

f. Full Blood Count & film (haemoglobin, white cell count and differential, and platelet count) Consensus achieved: strongly agree 99%

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g. Blood Culture Consensus achieved: strongly agree 84%

h. 1-2ml plasma to be separated, frozen, saved for later analysis if required No consensus achieved: strongly agree 67%

i. 1-2ml of acute serum to be saved for later analysis if required No consensus achieved: strongly agree 64%

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j. Urinalysis for ketones, glucose, protein, nitrites, and leucocytes Consensus achieved: strongly agree 94%

k. 10 ml urine to be saved for later analysis Consensus achieved: strongly agree 75%

l. Urea & Electrolytes (sodium, potassium, urea, creatinine) Consensus achieved: strongly agree 100%

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3. As a non-sterile urine sample is required for the core investigations, a technique for collecting urine should be in place as soon as the patient has had monitors attached, e.g. urine bag, clean catch collecting device, catheter Consensus achieved: strongly agree 85%

4. Comments

Speciality Comment Neurology

Evidence suggested that children who remain 'post-ictal' for more than 30 mins are more likely to have remote symptomatic causes for their convulsion so should be investigated. The need for other investigations in trauma cases depends on the cause of the trauma and whether it may be secondary to collapse/loss of consciousness of another cause

Nursing

I believe all children with reduced conscious levels should have core investigations done, collecting a urine sample is important but monitoring and other interventions may be required first in an emergency setting & is probably decided upon a case to case basis

Metabolic

Not sure the first question is categorically the case - core investigations might still be considered for postictal patients - esp. if first seizure

Neurology

Q1. For children post seizure they should have a history of epilepsy or febrile seizures OR this is obviously a febrile seizure. a new presentation of a prolonged seizure needs more investigation Q2 I would include urine organic acids

Emergency clean catch or catheter only Intensivist

Seizures should be defined as typical generalised epileptic seizure, to avoid confusion with "decerebrate" or opisthotonic attack from hydrocephalus +/- posterior fossa tumour, and focal fit which should not impair consciousness.

Intensivist Some children who are post ictal with a normal blood glucose may still require these tests

General paeds Core investigations need not be undertaken if presenting in post-ictal state with a history of either a seizure/ febrile convulsion

Nursing Although I see the importance of collecting urine, the patient being stabilised should take priority over urine collection.

General paeds

Sometimes an obvious cause of reduced conscious level becomes apparent fairly quickly such as sepsis, ingestion, NAHI and would not necessarily do all investigations saved samples are a good idea. I might start investigations listed in a child post seizure if the cause of seizure was not immediately apparent.

Emergency

core investigation should also include carboxyhaemoglobin and ECG and urine pregnancy test (in age appropriate), also include blood in urinanalysis

Intensivist

Answers would be easier if the meaning of 'Core' was defined. A child could be stable within 1 hour of convulsion due to, for example, meningitis and clearly need investigation.

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Speciality Comment Nursing

It depends on the possible cause of the decreased conscious level - you wouldn't need metabolic investigations for overdose or ingestion for example

Neurology Calcium and CRP also? Intensivist

1. depends what core Ix implied; trauma may have been caused by being unwell due to medical problem so still needs consideration. 3. faecal contamination however needs to be avoided

Emergency

If the reduced GCS is due purely to trauma, most of the additional tests are not required. E.g. urines, ammonia, amino acids.

Emergency

A limited number of core investigations are appropriate in trauma patients including cap. glucose, LFTs, FBC, urinalysis, UEs

Neurology

Once a cannula is in various 'baseline Ix' will be done automatically i.e. FBC U&E LFTs CRP (rather than blood culture) urine (depending often on age of patient). Hence would suggest considering adding CRP

Emergency Urine important but not an immediate investigation Trauma patients may still need investigation for reduced conscious level

Intensivist post convulsion- except known epilepsy should have core investigations with exception of ammonia, saved serum and urine

Neurologist Consider also how you are going to monitor urine output Emergency

I do not think that all of these investigations are mandated, it depends on the age and presentation of the child

Intensivist

The device to collect urine should be placed as soon a practically possible but some other interventions e.g. intubation and ventilation or vascular access and drug administration may need to occur after monitors but before urine collection.

Shock 5. Shock can be recognised clinically if one or more of the following signs are present in a child with

reduced conscious level:

a. Capillary refill time >2 seconds No consensus achieved: strongly agree 72%

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b. Plasma lactate >2mmol/l No consensus achieved: strongly agree 61%

c. Mottled cool extremities Consensus achieved: strongly agree 79%

d. Diminished peripheral pulses Consensus achieved: strongly agree 81%

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e. Systolic blood pressure is less than 5th percentile for age Consensus achieved: strongly agree 82%

f. Decreased urine output <1 ml/kg/hour Consensus achieved: strongly agree 78%

6. If shock is present in a child with reduced conscious level, look for signs of:

a. Sepsis Consensus achieved: strongly agree 94%

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b. Trauma (blood loss, tension pneumothorax, cardiac tamponade) Consensus achieved: strongly agree 97%

c. Anaphylaxis (urticarial rash, wheeze, stridor, swollen lips/tongue) Consensus achieved: strongly agree 97%

d. Heart failure (enlarged liver, peripheral oedema, distended neck veins, heart murmur) Consensus achieved: strongly agree 93%

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7. 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. Consensus achieved: strongly agree 94%

8. Comments

Speciality Comment

Intensivist Unless cause is obvious, e.g. bled out from open fractures, etc. Intensivist

Oliguria and decreased blood pressure may not always be diagnostic of shock. The same applies to elevated lactate.

Neurology Worth reiterating the APLS mantra of hypotension being a late sign of shock in children?

Intensivist

5. Cool extremities can occur with fever however; raised lactate can occur in metabolic disorders however; reduced urine output may be due to SIADH however.

Neurology

Yes; BP: not straightforward as initially response is raised BP and a 'low' BP is a late-v late sign.

Intensivist Urine output is late sign as is blood pressure. Need 2 or more of above Intensivist 5: the diagnosis of shock is phenomenally complex.

Neurology It is the combination of signs and clinical history that indicates shock rather than a

single examination finding Neurology CRT can be unreliable if patient is cool. Neurology I don't work in acute paediatrics so haven't answered these but I don't understand the

phrasing of Q7

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N

Response


62

9. Treatment - If shock is present in a child with a reduced conscious level, a fluid bolus of 20 ml/kg of crystalloid should be given, unless the child has diabetic ketoacidosis or signs of raised intracranial pressure, where a bolus of 10 ml/kg of crystalloid may be used and repeated if necessary. Consensus achieved: strongly agree 78%

10. The response to a fluid bolus should be monitored by detecting a positive response as defined as

one or more of:

a. A reduction in tachycardia Consensus achieved: strongly agree 90%

b. A reduction in a prolonged capillary refill time Consensus achieved – strongly agree 82%

0

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60

N

Response

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N

Response

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N

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63

c. An increase in urine output Consensus achieved – strongly agree 75%

d. An improvement in the level of consciousness Consensus achieved – strongly agree 85%

e. A reduction in lactate concentration, and/or improvement in base excess as measured by blood gas analysis


0

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50

60

N

Response

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N

Response

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64

f. Further fluid therapy should be guided by clinical response Consensus achieved: strongly agree 93%

g. Fluid boluses of up to or over 60 ml per kg may be required, guided by clinical response No consensus achieved: strongly agree 69%

h. If more than 40 ml per kg has been given, intubation and ventilation should be considered to prevent uncontrolled pulmonary oedema developing


0

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N

Response

0

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N

Response

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N

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65

i. If more than 40 ml per kg has been given with little clinical response, drug treatment to support the circulation should be initiated

No consensus achieved – strongly agree 73%

11. Comments


The metabolic effects of shock and indeed some of the clinical parameters may not correct immediately after initial treatment

Nursing

the FISH study is researching whether we should be giving 10ml/kg and review rather than 20mls /kg

General paeds I think APLS teaches bolus sizes of 10ml/kg in trauma also Neurology

Each piece of information should be considered in context - be careful not to put too much emphasis on improvement in a single parameter

Intensivist

Beware of implying that improvement in only one of these parameters is sufficient to stop further resuscitation measures. If others are also deranged, but have not responded, more may be needed.

Intensivist

The decision to intubate and ventilate takes clinical picture and underlying diagnosis into consideration. Fluid boluses in excess of 60 or even greater ml/kg may still not require this intervention

Intensivist No rationale for limiting fluid resuscitation boluses in raised ICP. should have a consistent approach across all causes of shock

Metabolic

Fluid therapy should be guided by clinical response and the suspected underlying pathology. E.g. risk of cerebral oedema in some metabolic disorders. Definite caution with need for other supportive measures for cases needing over 40ml/kg boluses. Septic shock may need over 60mls/kg.

Intensivist the use of a fluid bolus depends on the presumed course of the shock state Emergency fluid boluses should be 5-10mls/kg with rapid clinical assessment following re further

boluses Intensivist Why is a statement about BP missing? Neurology

Caveat: > 60mls/kg may be required but only prescribed by a senior doctor and 10mls/kg aliquots in trauma also?

Intensivist

9. If there is RICP they may require higher MAP to maintain CPP. 10. lactate - depends on cause; >60ml/kg should not be given without expert assessment

Intensivist

Fluid does not because pulmonary oedema- myocardial dysfunction does. You intubate to improve myocardial function by decreasing oxygen demand. In general the last 2 are 60ml/kg

Emergency

The management of these patients is complex and requires senior assessment at an individual level, I would be nervous about protocolising this too much.

0102030405060

N

Response


66

12. Ongoing management - 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.


13. Comments

Speciality Comment Intensivist It is 60ml/kg and will depend on many variables

Neurologist or retrieved to an appropriate unit urgently Emergency should only be monitored in ICU (not HDU) Intensivist Sounds like common sense to me!

Intensivist The child required high dependency care and this may be provided in a variety of settings

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N

Response


67

Sepsis

14. 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. A body temperature 13.1 of >38ºC


b. A body temperature 13.2 <36ºC No consensus achieved – strongly agree 67%

c. History of fever at home No consensus achieved – strongly agree 63%

0

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N

Response

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Not in m

y area

Response


68

0102030405060

N

Response


69

d. Tachycardia Consensus achieved – strongly agree 81%

e. Tachypnoea Consensus achieved – strongly agree 81%

f. A change in white blood cell count to >12x109/L No consensus achieved – strongly agree 67%

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N

Response

0102030405060

N

Response

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N

Response


70

g. A change in white blood cell count to <4x109/L Consensus achieved – strongly agree 81%

h. A non-blanching petechial or purpuric skin rash Consensus achieved – strongly agree 90%

15. A child with a reduced conscious level and suspected sepsis could have another underlying diagnosis and should have the core investigations requested.

Consensus achieved – strongly agree 82%

0102030405060

N

Response

0102030405060

N

Response

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N

Response


71

16. Comments: Speciality Comment Neurology

Many of these features are not 'exclusive' to septic shock, in absence of other explanation and after core investigations are complete, sepsis should be covered with broad spectrum antibiotics irrespective of individual findings on history and investigation

Nursing Question 15 was not clear. What is the change in white cell relating to? Still sepsis?

Neurology don’t understand question 15 Intensivist 14.1 & 14.2 are confusing! All parts in 15 are repeated? Nursing

A low temperature is more indicative of sepsis in young infants so this does not apply to all children

General paeds don't understand the question Emergency don’t understand the duplication Intensivist

Sloppy questions. Stray "13.1" & "13.2" in Q 14 confusing, and last statement of Q14 reappears in Q15. Any diagnosis of suspected sepsis needs immediate investigation to rule it out or confirm the source if possible, in addition to treatment, which has to be appropriate to source etc.

Neurology Egg DKA Intensivist don’t understand the question Metabolic post seizure or acute episode there may be a reactive neutrophillia Intensivist 15 duplicates questions in 14 Emergency I'm not sure that I understand the construction of the questions so may have

answered incorrectly? Neurology

Not sure what the difference with Q15 is Also assuming 13.1 and 13.2 in first 2 questions are typos?

Intensivist 15. Not quite sure what the question is here - repeat of above? Emergency

Sepsis should be suspected and treated regardless or any of the above signs. The benefits of antibiotics far out way the risks in this instance.

Emergency

Please review the wording of this question i.e. inclusion of numbers 13.1 and 13.2 and the repetitive statements of changes to the white blood cell count

Neurology raised white cell count could be due to prolonged convulsive seizure Intensivist 2 of them are not part of definition of SIRS but may be a consequence Neurologist Not sure I understand what question 15 is asking

17. A child with a clinical diagnosis of sepsis should be considered for the following additional investigations:

a. Chest x-ray


0102030405060

N

Response


72

b. Throat swab No consensus achieved – strongly agree 69%

c. Urine culture, if urinalysis positive for leucocytes and/or nitrites Consensus achieved – strongly agree 91%

d. Lumbar puncture Consensus achieved – strongly agree 87%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


73

e. PCR of blood for meningococcus and pneumococcus Consensus achieved – strongly agree 91%

f. Coagulation studies (activated partial thromboplastin time, prothrombin time, fibrinogen, fibrinogen degradation products)


g. Skin swab, if areas of inflammation are present Consensus achieved – strongly agree 79%

0102030405060

N

Response

0102030405060

N

Response

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N

Response


74

h. Joint aspiration, if signs of septic arthritis are present Consensus achieved – strongly agree 76%

i. A thick and thin film for malarial parasites, or rapid diagnostic test for malarial antigens, if there is a history of foreign travel to an endemic area


j. Cranial imaging (CT or MRI), if no other source of infection determined Consensus achieved – strongly agree 85%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


75

18. Comments Speciality Comment Nursing

Throat swab may have inherent risk of causing inflammation of further inflammation of the upper airway with a possibility for airway obstruction

Intensivist LP if deemed to be safe Neurology Brain imaging must be done before performing lumbar puncture in children

with GCS<15 Metabolic

Specify if throat swab is viral or bacterial - if viral agree but this may not be routine in all units and appropriate media is needed

Neurology All these should be considered though may not be indicated. Intensivist

If stiff neck, CT without delay, followed by LP if not contraindicated by findings, not after the rest has proven negative!

Intensivist

Lumbar puncture will depend on clinical status and may not be indicated when systemic signs of infection dominate. a Cranial CT may not be indicated in the absence of supportive history and examination

Neurology Even if capillary glucose is normal, will need a lab glucose Emergency urine culture even if dip negative To clarify Head or Brain cranial imaging as CT or MRI can involve other body

parts too. Neurology important that clinical assessment directs some investigations rather than all

tests for all children Neurology LP only when Child is considered safe to have it. Neurologist Bit non specific - this is like a paper from the journal of the b.... obvious Intensivist urine culture should be done even if the dipstix is negative for nitrites and

leucocytes

19. 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.


0102030405060

N

Response


76

20. 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


21. A child with a reduced conscious level and suspected sepsis should be reviewed by an experienced paediatrician within the first hour of presentation.


22. Comments Speciality Comment Intensivist 21: definition of experienced? Neurology

Not sure what you mean by 'poor response to treatment' in 20. I would want experienced paediatric review and discussion with intensivists and /or other specialities i.e. neurology before assuming child is not on the correct antibiotics

Emergency

19. IV antibiotics should not be delayed if all appropriate cultures can not be taken e.g. blood. 21. this should be Consultant review

Emergency Cultures should not delay iv 1st line antibiotics! Neurology Or senior ED doctor - consultant Intensivist Nothing substitutes for expertise! Intensivist

Some institutions may have robust protocols for second line antibiotics even when microbiological advice is not available.

Emergency

Rephrase 19 to - broad spectrum antibiotics should be given within 1 hour of initial presentation. Antibiotics should not be delayed beyond one hour over concerns that all microbiology samples have not been collected. re 21: rather than 'experienced' change to 'consultant' paediatrician

Emergency Inability to obtain blood culture should not delay antibiotic administration

0102030405060

N

Response

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77

Nursing paediatric clinician Emergency Q19. Sometimes it will be safer to start the antibiotics even if ALL culture

samples have not yet been acquired. Emergency or paediatric emergency physician in the first hour Intensivist

Should be immediately. treatment should have been fully initiated including 60ml/kg, inotropes and intubation in first hour

Neurologist Absolutely - no excuses. Consultants get paid large sums of money and this is what we should be doing.

Intensivist

Antibiotics should not be delayed for cultures if taking these has not been possible With respect to question 21 - this child should also be discussed with the local PICU team


78

Viral encephalitis (including Herpes simplex encephalitis HSE)

23. Recognition - Viral encephalitis, especially HSE should be suspected clinically in a child with reduced conscious level if the child has had two or more of the following:

a. A prolonged convulsion with no obvious precipitating cause


b. Focal neurological signs, including a focal convulsion Consensus achieved – strongly agree 84%

c. A fluctuating conscious level for 6 hours or more or the child has or has been in contact with herpectic lesions


0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


79

24. The clinical suspicion of HSE can be strengthened by:

a. A magnetic resonance image scan with non-specific features if herpes simplex encephalitis is suspected


b. An abnormal EEG with nonspecific features of herpes simplex encephalitis No consensus achieved = - strongly agree 66%

c. A positive CSF PCR result for herpes simplex virus DNA Consensus achieved – strongly agree 84%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


80

25. Comments Speciality Comment Neurology

In infants PCR may be negative, early MR may be non-specific and EEG show diffuse slowing rather than focal periodic discharge

Metabolic

Clarify the phrase "nonspecific features" - sometimes the MRI and EEG will show focal temporal abnormalities which are quite specific for HSVE

Neurology

if the MRI and EEG are non-specific they may point the way to this being an infectious encephalitis but don't distinguish e.g. between HSV and enterovirus for example

Emergency EEG not practical in most of these settings. General paeds

CT scan would be a useful urgent alternative to MRI and more likely to be available out of hours/WE Turnaround time for PCR is still too slow.

Neurology

CSF PCR is a useful test but can be false negative if LP is done in the first 2 days of symptoms. An EEG may help but does not need to be done very acutely. An MRI should include DWI as this is very sensitive for HSV encephalitis

Intensivist

First two questions in 24 are too ambiguous. What are 'non-specific features' on MRI and what are 'non-specific features of HSE' on EEG? Do you mean meningeal enhancement, PLEDs or what?

Intensivist

24. Not sure why you are stating 'non-specific features of' when they can be very specific? Hence my answer had to be neutral but not because I have a neutral opinion! 9 if specific features.

Neurology

MRI and EEG will only lend more support to HSE if specific findings of temporal involvement or temporal spikes (although these can be found in other encephalitides too); neither are sensitive nor specific (although temporal lobe involvement on MRI is more so than EEG findings).

Neurologist "A magnetic resonance image scan with non-specific features if herpes simplex encephalitis is suspected" does not make much sense, and neither does the nonspecific EEG. Surely this should be specific signs. Of these the EEG is less relevant for early diagnosis than the MRI

Neurology If child is febrile with new onset focal seizures. HSVE should be investigated and treated for

26. Treatment - If viral encephalitis is suspected clinically then intravenous aciclovir 10 mg/kg (or 500 mg/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.


0102030405060

N

Response


81

27. If HSE is confirmed or highly suspected then intravenous aciclovir should continue:

a. For 14 days No consensus achieved – strongly agree 36%

b. For 21 days. No consensus achieved – strongly agree 37%

28. Intravenous aciclovir can be stopped before 14 days of treatment if there is no ongoing clinical suspicion of HSE.


0102030405060

N

Response

0102030405060

N

Response

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82

29. In severe cases, the immune-compromised, or relapses, when PCR was initially positive, repeat lumbar puncture for CSF PCR 3 weekly until negative, and keep on intravenous aciclovir until negative.



Age of child seems to be important in determining length of treatment with new evidence that younger children are more likely to relapse after short courses of treatment. If Acyclovir ahs been started empirically without strong suspicion or likelihood of HSV then reasonable for experienced clinician to stop treatment

Neurology

21 days was suggested in the past to reduce the risk of relapse, however I think those that relapsed may have had an autoimmune encephalitis (NMDA)

Intensivist

27: 14 days minimum, 21 days if immunocompromised 28: stop once CSF confirmed negative for HSV

Nursing 27. Depending on response Neurology

Q27 & 28 "ongoing clinical suspicion" needs to be defined; if in doubt I would get neurology opinion. The recently recognised autoimmune encephalitides e.g. NMDAr must be considered/investigated Q29 cannot be answered without a neurological review of the case which would be better than a care pathway with recommending this management for all severe cases. Again. Alternative diagnoses must be considered.

Intensivist 26 is badly framed - who waits to perform an LP if it's contraindicated?? Intensivist

Aciclovir may be stopped if no ongoing clinical suspicion nor laboratory evidence (Blood, CSF) of HSV infection

Nursing I would not be making these decisions in practice General paeds Have not come across this situation and would seek tertiary advice first. Neurology MRI findings should also be used to help decide when to stop aciclovir Neurology unsure about 3 weekly CSF Intensivist

Current guidelines sometimes link duration of Aciclovir treatment to age. 'no ongoing clinical suspicion' obviously presupposes negative PCR on all samples

Intensivist 28. Does this mean did have HSE and improved or never had HSE? Can’t answer accurately.

Emergency I would consult paeds ID and micro on these specifics Neurology Above is often done in liaison with ID advice. Neurology

This is a difficult area. I involve our helpful Immunology colleagues in making decision about continuing / stopping IV Aciclovir...

Neurology

28- if clinical suspicion strong at the outset and child febrile continue for 3 weeks 29- I would liaise with immunology colleague

Neurologist Depends on how strong the clinical suspicion is - large amounts of Aciclovir are used with minimal good evidence of HSE

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Response


83

Speciality Comment Intensivist The dose of aciclovir for suspected CNS infection that I use is 20mg/kg tds


84

Tuberculous Meningitis

31. Tuberculous meningitis should be suspected in a child with a reduced conscious level if:

a. There are clinical features of meningitis No consensus achieved – strongly agree 60%

b. There has been contact with a case of pulmonary tuberculosis Consensus achieved – strongly agree 87%

0102030405060

N

Response

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N

Response


85

c. The CSF opening pressure is high, the CSF is cloudy or yellow, contains slightly increased cells (<500), which are lymphocytes, with a low or very low CSF/plasma glucose ratio (<0.3), and a high or very high protein (1-5 g/L)


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N

Response


86

32. Comments Speciality Comment Neurology You can't consider TB in all cases of meningitis in the UK but might consider if

history of foreign travel etc. Emergency Slow onset and now high fever spikes??? Intensivist Impractical to suspect TBM in any child with only reduced conscious level, except

in heavily endemic areas. Intensivist History is of very high importance in influencing index of suspicion General paeds

This in very rare in our area. I have not seen a case in 13 years as a consultant and only 1 or 2 as a registrar (east Mids.)

Neurology TB meningitis is uncommon unless there is a history of pulmonary contact or travel to endemic areas

Intensivist

First statement is poor/unhelpful. Of course TBM falls in the differential diagnosis if their are clinical features of meningitis but index of suspicion would be low in a child with a typical presentation of acute meningitis and no risk factors or associated features in history, exam and investigations

Neurology

TBM needs a low threshold for consideration and often the typical history of contact is not elicited initially (stigma) and depending if/when LP is performed the 'classical findings' as described above are also not necessarily present. Consider adding: blood Interferon gamma release assays for TB as a test

Neurology

TB meningitis can have various CSF features. It should be in differential diagnosis of any child with suspected meningitis who isn't improving on broad spectrum IV antibiotics and IV Aciclovir.

Neurology or there are radiological features of basal meningitis to suggest TBM Neurologist low CSF glucose not so common as very high protein in CSF


87

Metabolic Illness Hypoglycaemia

33. Diabetic ketoacidosis can be diagnosed if all three of the following are present in a child with a reduced consciousness:

a. A capillary or venous blood glucose of 11.0 mmol/l or more


b. A capillary or venous blood glucose of 11.0 mmol/l or more


c. A capillary or venous blood glucose of 11.0 mmol/l or more No consensus achieved – strongly agree 69%

0

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1 2 3 4 5 6 7 8 9 10 11

N

Response

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Response

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Response


88

34. Comments Speciality Comment Neurology Not sure how to answer this - should this not be a question with 1 line

rather than 3 ?? Nursing Would normally make blood ketones plus or minus urine ketones Nursing

I am unsure as to whether the blood glucose should be defined as 11 or more or whether it should be defined as lower as patients have been observed as having a DKA with a blood glucose of 10 & also patients often recognise they are in DKA due to an elevation in their blood sugar from their own defined 'normal' ranges

Metabolic

Why is this in the section on hypoglycaemia? I would add with an appropriate background history - as some of these may be stress markers

Nursing we use 15 mmol/l or more Neurology Presence of blood ketones is used in our department. Intensivist These findings are non specific and may be found in a number of other

clinical situations General paeds

We are doing blood ketones now should this be included in the core screen. May take time to get urine sample

Intensivist not sure this is how best to present info Emergency or capillary blood ketones Metabolic

Some metabolic diseases can mimic diabetic ketoacidosis so this needs to be borne in mind. e.g. organic aciduria

Intensivist

Sounds reasonable although if DKA is diagnosed in a patient with glucose of 11.1, pH of 2.9 and ketones of 3.1. it is mild and may not explain decreased conscious level

Neurology

Hyperglycaemia Does a pH of 7.29 causes a reduced conscious level? In a known diabetic, I would think of other causes too

Emergency Can get these levels in stress response, dehydration etc. Neurology

Glucose above 11 and pH less than 7.3 can be a stress response and raised ketones non-specific. History key and unlikely to have reduced LOC if this mild a metabolic derangement

35. 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:

a. Plasma lactate


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N

Response


89

b. Plasma insulin Consensus achieved – strongly agree 88%

c. Plasma cortisol Consensus achieved – strongly agree 87%

d. Plasma growth hormone Consensus achieved – strongly agree 75%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


90

e. Plasma free fatty acids Consensus achieved – strongly agree 75%

f. Plasma beta-hydroxybutyrate Consensus achieved – strongly agree 76%

g. Acyl-carnitine profile (on Guthrie card or from stored frozen plasma) Consensus achieved – strongly agree 78%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


91

h. Urine organic acids Consensus achieved – strongly agree 82%

i. Plasma amino acids Consensus achieved – strongly agree 82%


Think there should be 1st line and second line tests here, so would be better to say a child should have a serum sampled stored/frozen so that other tests can be done if no clear explanation for the hypoglycaemia

Metabolic

acylcarnitines - preferably both samples NB Insulin will need to have been frozen upon receipt in lab - this therefore needs to have been specified NB Also specify urine ketone testing which will be available much more quickly than plasma betahydroxybutyrate

Intensivist

Some children may not need the full profile. For example, the child with vomiting and decreased intake over a period of time leading up to presentation

General paeds and ammonia Emergency a pre-packaged request pack for ED is useful Metabolic core investigations should also include liver function tests and ammonia Metabolic Urine dipstick for ketones would suffice compared to plasma Emergency

Recommend that departments should prepare a local 'paediatric hypoglycaemia' box that list the appropriate investigations to send, pot colours needed (i.e. which types of specimen / blood), minimum volume of samples required, whether needs to be iced etc.

Neurology Ammonia and C Peptide too? Ward urine dipstick also helpful Emergency You may wish to consider an associated age range for some of the above

investigations

0102030405060

N

Response

0102030405060

N

Response


92


Agree with above (35) but would technically also consider liaising with metabolic team depending on history

Neurology I would want a paediatric endocrinologist to support these tests. They are my personal practice

Neurologist depends on clinical situation - they would be done in logical order Emergency

Depending slightly on the history - full screen not required if obvious cause for hypoglycaemia, e.g. ingestion of oral hypoglycaemics or profound diarrhoea

Metabolic Plasma ammonia measurement is vital

37. The emergency treatment of hypoglycaemia in a child more than 4 weeks old is an intravenous bolus of 2 ml/kg of 10% dextrose.


38. An infusion of 10% dextrose solution should be administered to maintain the blood glucose between 4 and 7 mmol/l.


0102030405060

N

Response

05

1015202530

N

Response


93

39. 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.


0

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60

N

Response


94

40. Comments Speciality Comment Intensivist 37: 5ml/kg Metabolic

This need not be urgent - a general paediatric consultant should be able to manage the child with hypoglycaemia as above (ensure correct samples taken and give sufficient dextrose) The tertiary discussion can in most cases wait until working hours - or even, if the child recovers appropriately, until the preliminary results of hypoglycaemia screen is back

Neurology

Q39 what does "urgent" mean there aren't many endocrinologists and virtually no metabolic specialists who do on-call

Intensivist

The response to initial bolus and ongoing blood glucose will determine the need for amount of dextrose needed for ongoing infusion and for referral to endocrine or metabolic specialists

General paeds

A decent general paediatrician should be able to investigate fully and then refer if a metabolic or endocrine diagnosis is made. Most are ketotic hypoglycaemia and these can be managed by a generalist

Metabolic

10% dextrose solution should also contain electrolytes (sodium and if plasma potassium checked and passing urine; potassium)

Emergency Not sure how many units have access to an on-call endocrinologist. Neurology

10% Dextrose ivi needs additives, not dextrose alone Only children with ongoing hypoglycaemia/high glucose requirements need urgent specialist support. We Generalists manage the majority unassisted!

Intensivist 39. urgent if not responding Neurology Although not in my area, Agree with above. Emergency Depends on the history and presentation Intensivist The dextrose infusion must include 0.9% saline as well and not just be

dextrose water.


95

Hyperammonaemia

41. Recognition - A plasma ammonia sample should be taken from a free-flowing venous (or arterial) sample and be taken immediately the laboratory, who should be informed in advance of its pending arrival. If any delay longer that 10 minutes is expected before analysis, then the sample should be transported on ice. Samples that are not transported and analysed urgently are not interpretable.

a. A plasma ammonia level of 100 micromol/l is significantly raised and needs actively

treating Consensus not achieved – strongly agree 22%

b. Only a plasma ammonia level of 200 micromol/l is significantly raised and needs actively treating

Consensus not achieved – strongly agree 46%

0102030405060

N

Response

0102030405060

N

Response


96

42. Investigation - A child with a reduced conscious level and a significantly raised plasma ammonia level should have the following tests requested from the saved samples, which were taken with the core investigations, or from a fresh venepuncture and urine collection.

a. Plasma amino acids profile


b. Coagulation studies – activated partial thromboplastin time, prothrombin time, fibrinogen, fibrinogen degradation products


c. Urinary amino acids profile Consensus not achieved – strongly agree 64%

0102030405060

N

Response

0102030405060

N

Response

0102030405060

N

Response


97

d. Urinary organic acids profile Consensus not achieved – strongly agree 64%

e. Urinary orotic acid Consensus not achieved – strongly agree 48%

43. Comments Speciality Comment Metabolic

And acylcarnitine profile which may give earlier indication of an organic acidaemia Orotic acid should be determined on organic acid analysis in most labs so may not need separate requesting in order to keep things simple Plasma amino acids are more important than urine An ammonia of 100-200 may be significant in an older child but not necessarily in a sick neonate

Neurology

Q41 ammonia level of >100 (and arguably>200) needs repeat before treatment. I wouldn't treat >100 but would defer to metablic specialist advice

General paeds In a DGH I would be taking the advice of a metabolic paediatrician Intensivist

The differential diagnosis of raised ammonia must be considered as well as the evolution of the level over time

Nursing I would be alerted by an ammonia level >100 Neurology

Test urine for ketones if the ammonia is high, even if receiving glucose. Discuss a high ammonia level with a metabolic consultant

Emergency I would be guided by senior paediatric advice on this Metabolic A plasma ammonia level of 100micomol/l is possible in the very ill

child; it should be monitored to ensure it is not rising. Intensivist

answers to 41 depend on clinical context - so not all ammonias > 100 need treatment but ammonia of 100-200 needs treatment if

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Speciality Comment underlying diagnosis makes further rise likely and also depending on the reference range of the lab

Neurology

An ammonia over 100 should be discussed with a tertiary metabolic specialist and they decide given the clinical scenario, what level needs actively treating

Neurology Yes to all of above but would also need metabolic input Neurology

I am a Paediatric Neurologist. Hence will not see these children as a first point when they come to hospital but I agree with above and strongly recommend that early discussion with Metabolic colleagues is vital for advice.

Metabolic

Interpretation of plasma ammonia concentration would depend on the clinical condition, the quality of the sample, age of the child etc.

44. Treatment - As soon as a significantly raised plasma ammonia level is detected, contact the nearest metabolic medicine centre for advice.


45. Sodium benzoate should be given with a loading dose of 250 mg/kg (diluted in 15 ml/kg of 10% dextrose) over 90 minutes.


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46. After the loading dose, give a further infusion of sodium benzoate 250 mg/kg (diluted in 15 ml/kg of 10% dextrose) over 24 hours.


47. If the plasma ammonia remains significantly raised up to 500 mmol/l and has not improved with the sodium benzoate infusion after 6 hours, the child should be considered for emergency haemodialysis.


48. 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.


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49. Comments Speciality Comment Nursing

This is not a common presentation in the ED where I work and therefore outside my area of expertise

Intensivist 47/48: Should haemodyalysis say haemofiltration? Metabolic

Emergency treatment should incorporate Sodium Benzoate, Sodium Phenylbutyrate AND L-Arginine IV I would prefer "diluted to a maximum concentration of 50mg/ml in 10% dextrose"

Neurology I would defer to metabolic advice for Q 44-48 & think a local guideline should be agreed.

Emergency

Phenylbutyrate, Arginine, Carnitine and carbiglue should also be started along side sodium benzoate to treat all potential urea cycle defects and reduce ammonia levels as well as considering haemofiltration after six hours of treatment.

Neurology I would discuss with metabolic team prior to selecting treatment regime and dose.

Intensivist

access to metabolic specialists may vary; advice may be sought from other sources including local intensive care units, paediatric neurologists and nephrologists

Neurology take metabolic advice General paeds

In this situation I would consult our local guidance and use our metabolic black box in conjunction with advice from metabolic team. I cannot answer these questions without referring to all of those.

Intensivist not exclusively haemodialysis - any form of extra-corporeal renal replacement therapy e.g. CVVH

Neurology

This is a rare and specialist area. The main focus of the guideline should be to remind people to do the test, get it to the lab on ice and to seek help if high

Metabolic

Uncontrolled ammonia >350mcmol/l is an indication for dialysis. Dilute loading dose in infants with 5% dextrose to avoid marked hyperglycaemia. Dilution 15ml/kg may give significant fluid load- 50mg/ml dilution avoids large fluid load, especially if risk of cerebral oedema.

Intensivist would need to double-check but these sound correct Intensivist

I would look up the sodium benzoate dosing regimen on the British Metabolic Group website. I cannot remember it. The child should be considered for haemofiltration at the time an ammonia remains significantly raised up to 500 is recognised as transport to a centre who can do this as well as placement of a dialysis catheter can take time in a small baby.

Metabolic THE BIMDG guidelines should be followed. WWW.BIMDG.ORG.UK


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Non-hyperglycaemic ketoacidosis

50. Non-hyperglycaemic ketoacidosis is present in a child with 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, or fresh samples taken:

a. Plasma lactate


b. Plasma amino acids No consensus achieved – strongly agree 67%

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c. Urinary amino acids profile No consensus achieved – strongly agree 66%

d. Urinary organic acids profile No consensus achieved – strongly agree 64%

51. For any child with non-hyperglycaemic ketoacidosis, advice should be obtained urgently from the nearest metabolic medicine unit.


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52. If plasma lactate levels rise to 9 mmol/l or more obtain urgent advice from the nearest metabolic medicine unit.


53. Children with non-hyperglycaemic ketoacidosis are at risk of raised intracranial pressure, therefore careful monitoring of their fluid balance is required.


54. A child with non-hyperglycaemic ketoacidosis will need nutrition restarted early to prevent further catabolism.


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55. Comments Speciality Comment Metabolic

NB lactate should be interpreted in clinical context, especially if coexistent shock Specifying pH<7.3 will pick up a number of children who have mild ketosis and acidosis - though one wouldn't necessarily expect these to be encephalopathy.

Neurology Q51-55 again local guidelines need to be agreed rather than trying to obtain OOH advice

Intensivist The source of advice in these situations may vary depending on the institution and local expertise

General paeds

This should all be in conjunction with metabolic team. As individuals we see this kind of event too rarely to manage safely with a guideline alone.

Metabolic

Plasma/blood spot acylcarnitines is another useful test in non-hyperglycaemic ketoacidosis. Nutrition is needed to prevent further catabolism under the guidance of a specialist metabolic dietician as the protein is likely to be restricted.

Emergency

ethylene glycol poisoning etc. should be considered with raised lactate levels in addition to metabolic causes

Neurology

Again, if the child has responded to basic treatment, they don't need urgent discussion with a tertiary centre. (i.e. the slim child with gastroenteritis who improves with iv fluids) Essential to have a hypo screen done though.....

Emergency 54. As far as I know, these children need specialised nutrition early. Emergency Again, depends on the history and presentation

Prolonged convulsion

56. If the convulsion is prolonged the core investigations should be sent.

a. At this first presentation Consensus achieved – strongly agree 81%

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b. At every presentation (e.g. in a child with an epilepsy or febrile convulsions) No consensus achieved – strongly agree 23%

57. If the convulsion is prolonged and the child is under a year of age, the plasma calcium and magnesium should be requested as well as the core investigations.

a. At the first presentation


b. At every presentation No consensus achieved – strongly agree 35%

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58. If the child is on regular antiepileptic drugs (AEDs) and has had a prolonged convulsion or cluster of more severe or frequent convulsions than usual, take a serum sample to send for their specific, named AED blood levels at every presentation.


59. Comments Speciality Comment Neurology Depends on the epilepsy syndrome and nature of seizure and the post ictal recovery

time Neurology Only if compliance is a concern or if drugs are metabolised easily.... many drugs can

not be measured. Neurology

for Q56-58 the samples do not have to be taken at every presentation ONLY if a diagnosis of the type of epilepsy has been made or if the child is recognised to have recurrent febrile convulsions Q58 it is not possible to measure the levels of some of the newer AEDs so local advice should be available

General paeds Not always, but at least consider it. Emergency Depends on drug and known compliance. Neurology Routine measurement of AED levels not used in our department. Intensivist

Samples for AED should be taken where known ranges of therapeutic concentrations are available and testing is accessible and standardised

General paeds

56/57 questions- Child with a neurological diagnosis such as epilepsy with or without comorbid conditions, presenting with prolonged convulsion, will need a review and core investigations guided and directed by the background knowledge

Neurology store serum for potential AED level testing and discuss with a neurologist is more appropriate

Intensivist AED levels not useful except e.g. insufficient carbamazepine - indicates metabolism +/- compliance

Neurology

In my opinion, this investigation is very important and frequently doesn't get done. In adult population it is recognised that 25% of Status epilepticus presentation are due to poor drug compliance.

Neurologist only for a few aeds

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60. If the plasma sodium is less than 125 mmol/l and the convulsion is ongoing despite anticonvulsant treatment, an infusion of 5 ml/kg of 3% saline should be given over one hour.


61. 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 0.5mmol/kg of 10% calcium gluconate should be given over 5 minutes (note that this precipitates if given simultaneously in the same IV line with ceftriaxone).


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62. If the plasma magnesium is less than 0.65 mmol/l and the convulsion is ongoing, an infusion of magnesium sulphate 50 mg/kg (0.2 mmol/L) should be given over one hour.


63. Comments

Speciality Comment Intensivist 60: titrate to response 61: calcium chloride Neurology

Need to be careful about management of hyponatraemia and rapid correction precipitating extrapontine myelinolysis

Intensivist

60: should say hypertonic saline as we stock 2.7% not 3% 62: As per local policy - our policy allows Mg to be given much quicker

Neurology

60-63 I agree that Na, Ca or Mg should be given but am not involved at the acute stage with their dosage/administration. However the Na correction looks too fast for me and should be worked out over 12-24 hrs

Neurology I am not sure of exact formulation and dose of treatments in this setting. Intensivist

Appropriate investigations must be sent off (or saved) prior to infusions to aid in establishing underlying diagnosis

General paeds

higher dose of magnesium

Nursing We would correct the sodium, calcium and magnesium as per local guidelines/BNF. I’m unsure of the doses!

General paeds

Definitive statements for these would be useful in a guideline.

Metabolic While I agree about corrections I am less sure about the doses as I would seek advice.

Intensivist magnesium infusion can be given over 20 minutes Intensivist rate of correction of Na in q 60 seems rather rapid - hence lukewarm agreement Neurology Individual units may well have their own local guidelines re above Neurologist For point 60- NICS is producing a guideline on this. It is not 5mlkg. the 2 should be

aligned preferably Emergency Should question 62 not be 0.5 - I am assuming this is a typo - even then, it is a

high dose Intensivist Expert advice required Metabolic

I would give 3% saline for a low sodium but not 5 ml/kg 10% calcium gluconate cannot be given peripherally so needs central access or dilution Again MgSO4 needs to be a 10% solution of more diluted to administer peripherally

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Post-convulsion state

64. After a convulsion has stopped, a child will often have a period of reduced consciousness, the post-convulsion or ‘post-ictal’ state, which 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, but if the capillary Blood Glucose is normal, and there are no other indications, other tests, including the core investigations may be deferred.


65. After the first hour of the post-convulsion state, if the child has not recovered to a normal conscious level the core investigations should be performed.


66. Comments Speciality Comment Neurology Depends on the nature of the seizure. recovery time and other factors in

history/examination Nursing

in children who are post ictal I have observed that bloods are taken at this stage whilst the child is being observed

Neurology If child has known epilepsy and the post-convulsion state is usually long, core investigations can be deferred.

Nursing Deferral should be based on the child's usual pattern of recovery post-convulsion. Neurology Q64 Again it depends on whether a diagnosis of epilepsy has been made and not for a first

presentation (isn't this really a duplicate question?)

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Speciality Comment Neurology Depends on whether this is initial or repeat presentation - some children take longer than

one hour to wake up. Intensivist

The history, examination and initial investigations will determine the need for core investigations. For example, if the child has improved but not "normal" after one hour it may still be appropriate to defer these investigations

General paeds

I would wait a little longer if known to have epilepsy

Nursing 65 - time of day/night should be taken into consideration Intensivist May be appropriate to defer after a senior review Emergency

It depends a bit on whether the child is known to have epilepsy and has been given rescue treatment on when to do core investigations like a CT scan. These can be over ordered. Discussion with a neurologist is recommended if unsure

Metabolic It depends on if the cause of the convulsion is known Intensivist

Qu 64. What about, for example, meningitis? If not done immediately, they should be done after one hour. I prefer statement 64 to 65.

Nursing

I think a child known to have prolonged seizures would not always need investigating within one hour; other factors need to be taken into account such as the time of day, amount of meds administered and previous patterns of seizures. History from the main carers is essential

Neurology Assume this refers to brief convulsions? Prolonged convulsions should all have core investigations

Emergency 64; ambiguous. Still not clear what is considered 'core' investigation Emergency Please specify whether this is a first seizure presentation Neurology Other factors likely to influence 65 66 responses Neurology Over reliance on capillary blood glucose should be avoided. Plasma glucose should be sent. Emergency Depends if the child often has a prolonged post ictal state Emergency

Some children are known to take 2-3 hours to come round. The decision to investigate further should depend on what is normal for that child and may be started after only 15-20 minutes if the child usually recovers that quickly or deferred for 2-3 hours if they normally take that long to come round.

Neurology

some children take more than an hour to recover so regular monitoring required and if improvement after 1 hour occurring all core investigations not required

Neurologist

If I disagree with question 64, then I have to disagree with question 65, as I am arguing that they should rarely be delayed

Metabolic

The core investigations should be performed asap as these include cultures which should be obtained before antibiotics if possible and antibiotics should be given within one hour (surviving sepsis initiative).


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Round 2 Observations and Capillary Glucose 1. Consider recording the following observations every hour in a child with a decreased conscious

level:

a. Heart rate Consensus achieved: strongly agree 95%

b. Respiratory rate Consensus achieved: strongly agree 95%

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c. Oxygen saturation level Consensus achieved: strongly agree 95%

d. Blood pressure Consensus achieved: strongly agree 98%

e. Physical appearance/state Consensus achieved: strongly agree 95%

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f. Temperature Consensus achieved: strongly agree 77%

2. Changes in conscious level should be observed every hour in a child with a decreased conscious

level:

a. At presentation with reduced conscious level Consensus achieved: strongly agree 98%

b. Every 30 minutes if GCS greater than 12 or V on the AVPU scale No consensus achieved: strongly agree 66%

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3. Changes in conscious level should be observed and recorded by a Glasgow Coma Score/modified Glasgow Coma Score (GCS) or AVPU:

a. At presentation with reduced consciousness


b. Every 15 minutes if GCS less than or equal to 12 or V on AVPU Consensus achieved: strongly agree 84%

c. Every 30 minutes if GCS greater than 12 or V on AVPU No consensus achieved: strongly agree 64%

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d. A decrease in GCS/AVPU indicates urgent medical review Consensus achieved: strongly agree 100%

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4. Comments Speciality Comment Paediatric neurology

Consider exceptions: E.g. obvious sedative drug treatment contributing to the level of consciousness.

Nursing Re. Q2 - would make more sense if question read "every 30 minutes if GCS12-14 or V..."

Paediatric intensivist more emphasis on GCS and less on AVPU please Neurologist if GCS remains stable over 4 hours monitoring can move to hourly once

GCS >12 Paediatric intensivist

For patients with only mildly decreased consciousness the frequency of formal reassessment depends rate of observed progression and to some extent underlying diagnosis


I’m struggling with the poorly conceived questions. I think children with a reduced conscious level need much more frequent observations than every 30 or 15 minutes. Does that mean I agree or disagree?


Vary observations by cause of decreased GCS, once known. Some require close monitoring for further deterioration, others not necessarily.

Emergency medicine Perhaps we should add urgent anaesthetic/ITU review if GCS <8 or P on AVPU


GCS will not pick up asymmetry i.e. focal signs developing hence pupillary size asymmetry etc. hence general obs also needed + neuro obs include BP AVPU is rather coarse to help assess as a one-off the initial presentation of a child, but is rather limited beyond that. Of note GCS was not standardised for use outside traumatic brain injury hence caution in seeing it as an 'alternative' to a neurological assessment

Paediatric neurology AVPU score is easier to use at presentation in non trauma cases. Paediatric intensivist/neurologist

2 and 3. >12 may mean normal so invalid question.

Emergency medicine Qu 1. remove 'consider' change to recommendation that should always measure

Metabollic

Monitoring for GCS > 12 or V depends on the trend. If fluctuating or trend decreasing would do 15 minute intervals

Nursing

The last part does not really make sense to me. If the child's conscious level appears to have deteriorated/reduced since arrival might be a better way to phrase it


Overnight and asleep needs to be considered - this may be more related to accuracy of assessment, and not in the emergency department situation.

General paediatrics

I would recommend hourly for GCS>12/V, every 30 mins for GCS <12-8 and every 15mins for GCS<8/P

Emergency medicine ANY REDUCTION IN GCS = 15 MINUTE MONITORING IN THE ACUTE PHASE

Emergency medicine 'greater than 12' can mean 15 - need careful wording in the guideline Paediatric neurology

The frequency of observation depends on the diagnosis and change in patient, a patient responding to voice or with GCS at 12, who is bradycardic should be monitored within a narrower time frame than 30 mins

Nursing

Every 30 mins if greater than 12? So does this apply if it's 14 or 15? Depends on the underlying cause of fluctuating or decreased conscious level

Emergency medicine Every 15 mins GCS is impracticable and probably not so useful overall. Neurologist

Depends on rate of change and direction of change of GCS; an unconscious patient in PICU would not need gcs every 15 minutes

Emergency medicine

Practically you cannot deliver more than 30 minute observations in ED or on an acute non PCCU/HDU ward. Important not to set standards that will lead to certain failure.


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5. In children with a reduced conscious level a borderline low glucose (2.6 - 3.5 mmol/l) should be repeated after 15 minutes.


6. In children with a reduced conscious level a borderline low glucose (2.6 - 3.5 mmol/l) should be

repeated after 30 minutes. No consensus achieved: strongly agree 52%

7. In children with a borderline low glucose (2.6 – 3.5 mmol/l) treatment should be instigated before

repeating the capillary glucose test. No consensus achieved: strongly agree 48%

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8. Comments Speciality Comments Paediatric neurology Initiating glucose treatment as soon as possible is good practice

particularly in younger infants Nursing

If the borderline glucose is suspected to be a causative factor in the reduced conscious level treatment should be instigated and blood glucose level repeated after 30 minutes

Paediatric intensivist recheck in 1 hour is enough Paediatric intensivist Local laboratory range of normal limits should be clear Manchester paediatric intensive care advanced nurse practitioners

Number 6 should perhaps read 'within 30 mins' rather than 'after' 30 mins as this could be interpreted as not before 30 mins


Again, the times here are arbitrary. Do I assume an intervention has taken place for 5. and 6. ? etc.

Emergency medicine

I don't like the value banding here, I would not ascribe low GCS to a BM of >3, the exception being in a known diabetic child for whom 3.0 might be low enough to make them unwell

Paediatric neurology Not sure if 'treatment of borderline low blood glucose ' level is evidence based

General paediatrics

In a child with reduced consciousness and borderline low blood glucose, I would be keen to treat before repeating the levels.

Paediatric neurology A true plasma glucose should be sent if capillary blood glucose test shows a low result.

Nursing I suppose it depends on guidelines about treating borderline glucose General paediatrics

6. Recheck sooner if becomes symptomatic 7. If treating presumed symptomatic hypoglycaemia, take appropriate screening blood and urine tests beforehand

Emergency medicine Re. 7 I assume you mean in those with a reduced GCS? Paediatric neurology

The cap glucose should be confirmed with a formal sample and then repeated within 15 minutes if there are no other explanations for the child’s altered consciousness, and if confirmed a dextrose infusion should be started rather than waiting for the lab result to be made available

Nursing

Depends whether it is an incidental finding or thought to be a contributing factor whether treatment is given

Neurologist Would recommend confirmation with lab glucose Emergency medicine Treatment should be instigated, but not if this includes a treatment bolus

of dextrose Emergency medicine

We do a formal laboratory measurement on all abnormal or borderline results and then treat while awaiting the results.


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Core Investigations 9. All children with a reduced conscious level should undergo core investigations, expect those:

a. Within 1 hour post-convulsion, who are clinically stable and have a normal capillary blood glucose


10. The core investigations for all other children with a reduced conscious level are:

a. Capillary blood glucose Consensus achieved: strongly agree 91%

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b. Laboratory plasma glucose Consensus achieved: strongly agree 84%

c. Plasma ammonia (a venous or arterial sample, sent directly to the lab) No consensus achieved: strongly agree 73%

d. Full blood count and film Consensus achieved: 86%

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e. Plasma liver function tests Consensus achieved: strongly agree 82%

f. Blood gas (arterial or capillary or venous – pH, CO2, HCO3, CO) Consensus achieved: strongly agree: 86%

g. Blood culture Consensus achieved: strongly agree 75%

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h. Consider separating and freezing 1-2ml plasma for later analysis if required No consensus achieved: strongly agree 59%

i. Consider saving 1-2ml of acute serum for later analysis if required No consensus achieved: strongly agree 59%

j. CT scan


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k. MRI scan No consensus achieved: strongly agree 48%

l. Blood alcohol No consensus achieved: strongly agree 48%


Some exceptions: Known situations such as diabetes, epilepsy. MRI preferred if available and safe. Alcohol level may have to be considered in older children only.

Paediatric intensivist CT, MRI not needed as core Neurologist MRI preferable to CT but not always possible and reality is that CT most available

quickly Paediatric intensivist

If the seizure is a new presentation then core studies are more appropriate than in those where seizures are known. MRI and blood alcohol will depend on the history and other clinical findings and may be informed by CT scan


Could the above be split into primary and secondary investigations i.e. All need to be done but some not as urgent as others.

General paediatrics

Where I have been less positive it is because clinical assessment, review pf history, development and age of child are relevant and may target my investigations


Structural imaging is essential without delay, whether by CT or MR in all children with sudden deterioration in conscious level, including non-epileptics who have had a seizure, in my view.

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Rather than blood alcohol could 'toxicology' be added; also how about Carbon monoxide level? CT and MRI would depend on ease of access and CT would often be more easily available

Paediatric neurology Blood alcohol in teenagers or history suggestive/suspicious in younger child. General paediatrics An initial CT scan will be helpful, A MRI scan might not always be possible at the

outset. Emergency medicine

Metabolic diagnoses are largely known about or are index presentations in infancy or preschool children. I don't think metabolic screening in older children is really necessary. Access and practicality of MRI does not make it my choice for 1st line imaging of a comatose child also the only MRI set up for intubated children in my region is in the tertiary centre 20 miles away, CT gives enough information re bleeding, fractures, diffuse axonal injury etc. to provide useful and timely diagnostic information.

Emergency medicine

Qu 9. Safer phrasing would be 'clinically improving' rather than 'clinically stable’ Qu 10. re blood alcohol testing - should add comment that alcohol intoxication can coexist with other pathologies also causing a reduced LOC (e.g. HI, poisoning, sepsis etc.) and other differential diagnoses should also be pursued and explored with a raised blood alcohol level

Emergency medicine

In the absence of trauma, CT head should only be undertaken if other tests do not reveal the source of reduced conscious level.

Paediatric neurology Urine for toxicology, organic acids. Nursing 9 - If they are known epileptics only 10 - spelling error in venous blood gas. Emergency medicine Blood alcohol not available in my trust Nursing

Investigations required very much depend on the age of the child, presentation and history and whether you have a clear diagnosis


Urine toxicology requested urgently; consider blood toxicology - I tend to ask for this more than alcohol. We've found all sorts like benzodiazepine, methadone, cocaine which don't have same clues as alcohol Also some blood gas machines show lactate, these are preferable - recently made a diagnosis of MELAS in a child with rapidly deteriorating consciousness based on this alone, previously thought to have an acute demyelinating episode.

Emergency medicine Guided by history and clinical findings General paediatrics

Further guidance needed for appropriate requesting of Ammonia, alcohol and Neuro-imaging as not indicated in all children and MRI not always available

Emergency medicine

q9 depends on first convulsion and febrile / non-febrile. Blood alcohol only useful as screening bedside test - not quantitative lab test "is alcohol on board?" not: "how much alcohol is in the blood?"


This would depend on history to a certain extent, in particular timing of neuro-imaging. CT would be preferred over MR for speed of access, reduced imaging time in unstable? Moving patient and ability to identify bleeds and fracture. In some cases if MR was available this may be imaging modality of choice but rarely before CT

Nursing

Again it will depend on the presenting circumstances; medical causes need more in depth investigation than trauma. A toxicology screen may be required to identify ingestion

Emergency medicine

MRI not useful acutely and takes time away from resuscitation and supportive care. Blood alcohol not usually indicated in paediatric group and would not alter management of supportive care.

Neurologist

modality and urgency of imaging depend on likely scenario - MRI is ideal but the patient should have some form of neuroimaging

Emergency medicine

It depends on the history and examination. We would not routinely do an ammonia, CT or an MRI. We would always do a metabolic screen and store a sample of blood and urine on children with low blood glucose.


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Cranial Imaging/Lumbar Puncture 12. The decision to perform a lumbar puncture in a child with a reduced conscious level should be

made by a consultant paediatrician, who has examined the child. (Treatment should be delayed if unavailable)



The decision could be made by a senior Paediatric trainee or s Associate Specialist or a staff grade depending on the level of experience. It would be useful to say that LP should ONLY be performed after brain imaging has been reported/reviewed by a radiologist.

Nursing

Other experienced, senior clinicians such as associate specialists, staff grades and advanced nurse practitioners may competently make this decision.

Neurologist This should be within the competency of a paediatric registrar Paediatric intensivist An experienced trainee/specialist doctor is capable of making this decision Manchester paediatric intensive care advanced nurse practitioners

Or suitably qualified person - there are some very senior experienced registrars


Or experienced senior registrar


For any possibility of meningitis, if structural imaging reassuring, I believe LP is important. Avoid if child is extending, as likely structural brainstem lesion, either direct or from herniation, and consider ventricular tap instead.

Emergency medicine

LP needs to be side-lined as juniors will delay lifesaving treatments i.e. antibiotics while they fret and dither about doing a test that helps very little when we can do meningococcal PCR on blood


Often an LP in that setting can be deferred until the child is seen as more stable or the team is happy that there is no intracranial SOL.

Paediatric neurology LP decision made by senior Registrar with consultation with consultant on call - consultant or PICU

General paediatrics Middle grade can make decision Emergency medicine SPR or above Nursing

The decision to LP should be at the very least be discussed with a consultant by a middle grade doctor if a consultant is not available

Paediatric neurology This is unnecessary. General paediatrics Or Senior Trainee Doctor Emergency medicine

Important to stress that diagnosis of meningitis can be made via CSF PCR up to 72 hrs after presentation and antibiotics

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Speciality Comment Paediatric neurology

If consultant is not on site, then child should be discussed with consultant by senior resident paediatrician. Safer to defer LP if in doubt and start treatment for CNS infection

Nursing This may not be realistic in all settings Neurologist

This is increasingly an area of controversy with far too few LPs being done and people having very strange ideas about contraindications for LP

Emergency medicine

Lumbar puncture should not delay treatment under any circumstances. I am not sure of the evidence to support "emergency" lumbar puncture.

14. Cerebrospinal fluid investigations should include:

a. Lactate No consensus achieved: strongly agree 68%

b. Sample to store for possible future investigations No consensus achieved: strongly agree 73%


it would be good to drive a standard of measuring CSF pressure, lactate and storing CSF every time an LP is done

Paediatric intensivist Additional tests, including lactate, may not be indicated in every case Paediatric neurology

Paired glucose and paired lactate are important as well as measuring the opening pressure of the CSF; paired oligoclonal bands may also need considering

General paediatrics Further guidance for indications for assay of CSF lactate needed-not appropriate for all children

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Lactate may be difficult to interpret if there is hypoxic ischaemic insult. Additional sample is very sensible but should be decanted and saved by path lab so done properly and not lost!


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Alcohol Intoxication 16. The commonest cause of acute intoxication leading to a child or young person having a reduced

conscious level is excessive alcohol (ethanol) ingestion.Care should follow the usual ABCD system (as in APLS), and include the core investigations. Look especially for and treat:

a. Hypoglycaemia with IV glucose and maintenance dextrose/saline


b. Hypotension Consensus achieved: strongly agree 89%

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c. Hypothermia Consensus achieved: strongly agree 91%

d. Consider haemodialysis, continuous veno-venous haemodialysis, continuous veno-venous haemofiltration or continuous veno-venous haemodiafiltration if severe intoxication or worsening coma, hypotension, acidosis, or with pre-existing liver disease.


17. Comments Speciality Comment General paediatrics The last interventions would be a PICU decision in a tertiary setting Neurologist If considering haemofiltration would be in communication with

regional PICU General paediatrics Would discuss with PICU team if concerned Emergency medicine

I think I would disagree with the statement at the top but agree with the management steps below it


Re haemodialysis etc. the relevant expert team would need contacting and discussing as this options is limited to a few centres


May require higher glucose than routine for maintenance

Emergency medicine

Add additional comment - history points from witnesses should specific enquire re ingestion of illicit drugs/legal highs & deliberate drug ingestion for self-harm. And re recent history of HI.

Emergency medicine

Agreed in severe toxicity but mild-moderate toxicity is common and over-treatment should be avoided

Emergency medicine

If you consider dialysis and others above, you really must speak to your friendly PICU consultant

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Speciality Comment Nursing Consideration of ingestion of other recreational drugs Emergency medicine In our local population, alcohol intoxication is NOT the most common

cause of reduced GCS. Emergency medicine

In my experience alcohol unlikely to need haemodialysis etc therefore this needs to be worded in a way that ensures people look for other causes of intoxication if getting to this level of treatment

Emergency medicine

I have worked in paeds ED for over 17 years and we have had over 700,000 patients through and I do not recall ever having to have a child "actively" managed for alcohol intoxication.


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Shock 18. Shock can be recognised clinically if one or more of the following signs are present in a child with

reduced conscious level:

a. Capillary refill time > 2 seconds No consensus achieved: strongly agree 61%

b. Plasma lactate >2mmol/l No consensus achieved: strongly agree 41%

19. The response to a fluid bolus should be monitored by:

a. Plasma lactate levels No consensus achieved: Neither agree nor disagree 34%

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20. Fluid bolus of up to or over 60ml per kg may be required, guided by clinical response Consensus achieved: strongly agree 77%

21. If more than 40ml per kg has been given with little clinical response, drug treatment to support

the circulation should be initiated No consensus achieved: strongly agree 61%


Should be considered - but will require ICU input and advice shock is not just about capo refill and lactate

General paediatrics

The addition of inotropes would be on the advice of the intensivist - who should be contacted at the 40ml/kg point.

Neurologist lactate should only be a factor in monitoring response as may be a primary lactic acidosis


Serum lactate is an adjunct only and levels may not correlate with either clinical improvement or deterioration. Many children who have received more than 40 or even 60 ml/kg do not need vasoactive drug support


19: Response to fluid bolus should 'include' lactate levels - wouldn’t be the only form of monitoring response 21: Should be 'considered'

General paediatrics

I would be very cautious about such large volumes of fluid in an unconscious child unless the diagnosis was obvious e.g. meningococcal septicaemia

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Cap refill is not very helpful as a measure of shock and its significance should be down played. Lactate is not the only measure of successful resuscitation and whilst it should go down with treatment other observations such as physiological parameters and urine output. 20.sounds like its 'ok' to give 60ml/kg when a child that shocked needs PICU....21 is better

Paediatric neurology High lactate can be due to other causes too Paediatric intensivist/neurologist

18. High lactate nay indicate metabolic cause and does not = shock 19. Include lactate but not only 20. Caution if requires 60ml/kg and would need expertise if >40/kg required 21. expert should be involved in decision

Nursing All of the child’s clinical signs need to be looked at when considering whether the child in in shock

Emergency medicine Again, be guided by clinical findings Emergency medicine

Shock is a clinical diagnosis and lactate is only one of the parameters to be observed following bolus - appearance, alertness, pulses etc. are probably more useful. If >40 ml given, speak to PICU cons?

Nursing

Prolonged CRT could be a temperature response and needs to be considered alongside HR and BP. A capillary blood gas lactate can be elevated with incorrect technique and needs to be interpreted carefully. HR, BP, RR all need to be monitored carefully alongside the conscious level

Emergency medicine

Plasma lactate is often over two in mildly reduced perfusion, and tracking it does not really help inform fluid management. In failure of response to fluid loading, selection of inotrope should be considered, not necessarily "should be initiated" - permissive hypotension can sometimes be required.

Emergency medicine

CR and lactate can both be unreliable alone so need to be associated with other clinical indicators not just one of these two.

Emergency medicine

It depends on the type of Shock. If hypovolemic shock secondary to haemorrhage we would use fluid after 40ml/Kg, in septic or anaphylactic shock 60ml/Kg plus would be required (in meningococcal disease upwards of 100ml/Kg) after 40ml/Kg and definitely by 60ml/Kg inotropes would be considered, Knowing the type of shock does refine the decision making.


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Sepsis Note - Unfortunately an error occurred for the questions on sepsis in this round of the Delphi which led to 0% response rate. These questions were therefore sent out again separately which explains the different response rate from the rest of the questions. 23. 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. A body temperature of >38°C Consensus achieved: strongly agree 95%

b. A body temperature of >36°C No consensus achieved: strongly agree 67%

0

5

10

15

20

N

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c. A history of fever at home No consensus achieved: strongly agree 72%

d. A change in white blood cell count to 12x109/L Consensus achieved: strongly agree 81%

24. A child with a clinical diagnosis of sepsis should be considered for the following additional

investigations:

a. Throat swab No consensus achieved: strongly agree 72%

0

5

10

15

20

N

Response

0

5

10

15

20

N

Response

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25. Comments Speciality Comment Paediatric neurologist I still think that the wording of question 6 is misleading and confusing.

You need to group the 2 signs that you are asking about together and not have 4 individual factors, for example 1 and 4 statements together might carry more weight than 2 and 3

Viral encephalitis Recognition 26. Viral encephalitis, especially HSE should be considered clinically in a child with a reduced

conscious level if the child has had two or more of the following:

a. A prolonged convulsion with no obvious precipitating cause No consensus achieved: strongly agree 73%

27. The clinical suspicion of HSE can be strengthened by:

a. A magnetic resonance image scan with non-specific features if herpes simplex encephalitis is suspected


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28. Comments Speciality Comments Paediatric neurology EEG may also help Nursing I am unfamiliar with the MRI findings in HSE Neurologist

Fever, focal seizures and an MRI in keeping with encephalitis should prompt treatment for HSV. EEG supportive


remember the autoimmune components and consider giving and referral for opinion re plasma exchange

General paediatrics More likely to get an urgent CT in the first instance. Emergency medicine

Again access to MRI is the problem, like the LP question we should get on and treat and confirm the diagnosis later


Focal changes on EEG can be suspicious or a focal seizure; however if in doubt treat with acyclovir is advice that is currently given until the CSF PCR is obtained


27. specific features

Nursing 26 does not have 2 options Paediatric neurology

Question 26 is incomplete. Question 27 does not appear to make much sense as it stands unless it's mainly about MRI. My clinical suspicion would be enhanced by specific types of lesions - anything suggesting an acute process - diffuse high T2 signal or heterogeneous signal; as well as obvious classic lesions

Emergency medicine Again, not useful in first hours of treatment so might delay prompt management

Neurologist Especially in lateralising features Emergency medicine If you can get one acutely out of hours. That is not a commonly available

service in most trusts. 29. Treatment - If HSE is confirmed or highly suspected, then intravenous aciclovir should continue:

a. For at least 14 days No consensus achieved: strongly agree 34%

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b. For at least 21 days No consensus achieved: strongly agree 32%

30. Intravenous aciclovir can be stopped before 14 days of treatment if there is no ongoing suspicion

of HSE (negative CSF and blood samples) No consensus achieved: strongly agree 50%

31. In severe cases, the immune-compromised, relapses, or if NDMA-R antibody positive, repeat

lumbar puncture for CSF PCR, and prolonged courses of aciclovir may be necessary. Consensus achieved: strongly agree 77%

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Response

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32. Comments Speciality Comment Paediatric intensivist Need micro advice on these General paediatrics

The duration of Aciclovir would be on the advice of neurology/microbiology in a confirmed case. I've no idea of the answer to number 31 - the "not in my area” button has disappeared!


Aciclovir may be stopped earlier than 14 days if laboratory, imaging and clinical investigations do not support HSV infection

Paediatric neurologist Prefer 21 days in case of 30 if severe presentation General paediatrics

Probably true but outside my area of expertise. I would discuss such a case with microbiology colleagues and infectious disease specialist at local tertiary hospital

General paediatrics

Microbiology consult might be helpful in deciding the duration of treatment if not straightforward


30. caution in interpreting PCR results depending on time n illness taken and treatment given

Paediatric neurology Discussion with immunology colleagues recommended for advice. Nursing

We would discuss the length of treatment with the virology/microbiology giving them the clinical history and progress of the patient

Emergency medicine Question 31 - not in my area Emergency medicine 31 not really my area Paediatric neurology

Prolonged acyclovir treatment is necessary in infants and younger children who may not have typical signs at presentation

Emergency medicine I would consult ID/virology about the duration of treatment


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Tuberculous Meningitis 33. Tuberculous meningitis should be considered in a child with a reduced conscious level if:

a. There are no clinical features of meningitis No consensus achieved: strongly agree 34%

34. Comments Speciality Comment Neurologist Would expect clinical signs and evidence of basal meningitis on imaging Paediatric intensivist

History is extremely important in cases where TB is considered. it should always be considered and may or may not be associated with clinical signs of meningitis


This is a confusing statement unable to answer

General paediatrics

This statement doesn't make sense to me. Incidence is very low locally. I would only consider it in certain ethnic groups or history of travel and diagnosis is unclear

Emergency medicine

I disagree with the above there is usually a steer here with history of indolent headache etc., ethnicity or contact with pulmonary TB sufferer

Paediatric neurology CXR; history of travel or of cough in family or of contact with TB General paediatrics Background clinical history will be relevant Nursing

you would expect a vague history of not being quite right for a few weeks before they presented with TB meningitis and a reduced conscious level

Emergency medicine

Unsure about the wording of this question - do you mean 'there are no features of bacterial meningitis;...?

General paediatrics EVEN if there are no clinical features of meningitis Emergency medicine

should be considered if: - high risk environment / family (recent case in person living in same house, active case recently returned from Asia / Africa, HIV+, insidious and prolonged onset, no high fever, cranial nerve involvement.....' No clinical features of meningitis is too broad???

Paediatric neurology As well as other diagnoses Emergency medicine

It should always be considered, regardless of meningitis features being present.

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Metabolic illness Hypoglycaemia 35. Diabetic ketoacidosis can be diagnosed if all three of the following are present in a child with a

reduced consciousness:

a. A capillary or venous blood glucose of 11.0mmol/l or more No consensus achieved : strongly agree: 59%

b. pH less than 7.3 No consensus achieved: strongly agree 61%

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Response

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c. Bicarbonate less than 15mmol/l No consensus achieved : strongly agree 57%

36. Comments Speciality Comment Paediatric intensivist a stress response in any critically ill child can result in all 3 need to involve

ketone measurement General paediatrics What about evidence of ketosis? Paediatric intensivist

All of these laboratory findings are non-specific and whilst DKA can be considered, further evidence is required


There are other pathologies that may present with the above so doesn't exclude DKA but doesn't initially confirm the diagnosis

Emergency medicine

BM 11 is too low a recent SI in our trust treated a child as DKA with a metabolic acidosis and raised BM in teh low teens; they had occult surgical abdomen and did not survive. The BM needs to be higher e.g. 20+, metabolic acidosis on a gas and ketones in teh urine or blood

Metabolic

DKA should be suspected rather than diagnosed with only those 3 criteria. An organic aciduria can give the same picture

Emergency medicine

Again - wording of question unclear

General paediatrics

Shouldn't it be HYPERglycaemia? Blood sugar of 11 seems slightly low What about urinary ketones?


I find these questions difficult to answer you ask if all three are present - why is there not 1 box rather than 3. I would say if all are present DKA would be high in the differentials, but may need to consider other factors in child not previously diagnosed - there are other causes of acidosis and blood sugar > 11 could be a 'stress' response.

Emergency medicine

ketones also need to be present.

Emergency medicine

Ketones in the urine.

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Hyperammonia 37. Recognition - A plasma ammonia sample should be taken from a free-flowing venous (or arterial)

sample and be taken immediately to the laboratory, who should be informed in advance of its pending arrival. If any delay longer than 10 minutes is expected before analysis, then the sample should be transported on ice. Samples that are not transported and analysed urgently are not interpretable.

a. A plasma ammonia level of 100 micromol/l is significantly raised and needs urgent

discussion and treatment No consensus achieved: strongly agree 32%

b. A plasma ammonia level of 200 micromol/l is significantly raised and needs actively treating


38. Comments Speciality Comments Nursing I am not sufficiently familiar with plasma ammonia levels to make an

informed decision. General paediatrics Both would be discussed with metabolic experts! Neurologist if 100- I would repeat to see the trend and look for a cause but not

actively treat Paediatric intensivist

The local normal range must be known. Raised ammonia may not require active intervention depending on aetiology and clinical picture

Paediatric neurologist recommend metabolic advice if unsure of significance

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Speciality Comments General paediatrics

if >100<200 may not need actively treating other than managing basic ABC. Does not necessarily imply a metabolic condition. Should seek advice.


Anyhow raised ammonias if sample taken correctly would normally be discussed with the local metabolic team

Paediatric neurology In urea cycle disorders NH3 is much higher than 200. Paediatric intensivist/neurologist

>100 needs discussed not necessarily treated

Metabolic

a plasma ammonia of 100 micromol/l needs discussing and monitoring but may not need active treatment

Nursing my suspicions would be raised with an ammonia above 100 however this is not my speciality


Again will depend on the whole clinical picture - I find it difficult to assess the relevance of these parameters in isolation. I think any unexpectedly high result needs to be considered before implementing treatment per se, but there will be other clinical factors that determine management

Emergency medicine I would have to check the normal/lab values before assessing this test. 39. Investigation - A child with a reduced conscious level and a significantly raise plasma ammonia

level should have the following tests requested from the saved samples, which were taken with the core investigations, or from a fresh venepuncture and urine collection.

a. Plasma amino acids. Coagulation studies activated partial thromboplastin time,

prothrombin time, fibrinogen, fibrinogen degradation products No consensus achieved: strongly agree 64%

b. Urinary organic acids profile No consensus achieved: strongly agree 62%

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c. Urinary orotic acid


40. Treatment - Sodium benzoate should be given with a loading dose of 250 mg/kg (diluted in 15

ml/kg of 10% dextrose) over 90 minutes. No consensus achieved: strongly agree 25%

41. After the loading dose, give a further infusion of sodium benzoate 250 mg/kg (diluted in 15 ml/kg

of 10% dextrose) over 24 hours. No consensus achieved: strongly agree 18%

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Response

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42. If the plasma ammonia remains significantly raised above 200 mmol/l and has not improved with the sodium benzoate infusion after 6 hours, the child should be considered for emergency haemofiltration.


43. A plasma ammonia level above 300 micromol/l requires emergency haemofiltration and transfer

should be arranged urgently, whilst starting the ammonia reducing treatments available locally. No consensus achieved: strongly agree 32%

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Response

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Non-hyperglycaemic ketoacidosis 44. Non-hyperglycaemic ketoacidosis is present in a child with 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, or fresh samples taken:

a. Plasma amino acids


b. Urinary amino acids profile No consensus achieved: strongly agree 50%

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c. Urinary organic acids profile No consensus achieved: strongly agree 64%

45. Children with non-hyperglycaemic ketoacidosis are at risk of raised intracranial pressure,

therefore careful monitoring of their fluid balance is required. No consensus achieved: strongly agree 64%

46. A child with non-hyperglycaemic ketoacidosis will need nutrition restarted early to prevent

further catabolism. No consensus achieved: strongly agree 43%

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Response

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47. Comments Speciality Comment General paediatrics Sorry, we would be guided by metabolic experts or intensivists here. Manchester paediatric intensive care advanced nurse practitioners

I would have to read a ratified guideline/drug book to confirm the doses of Benzoate

General paediatrics

I would always look up the local guideline and discuss with a metabolic specialist in this case. We have a "metabolic box" with the drugs and instructions for the common problems. I would not guess at any of these doses or management but presume that sensible doses are being suggested. A national guideline for the management of reduced consciousness should have clear guidance drawn up by metabolic specialists rather than by consensus from general paediatricians like me.

Paediatric neurology Yes for above Ix as in practice I would initiate these Ix and discuss further with relevant team


46. feeds may need modified

Metabolic

Other medications to treat hyperammonaemia should be started not only sodium benzoate. management of ammonia levels> 200micromol/l should also include discussion with a specialist centre

Emergency medicine I would seek advice from metabolic team and intensive care re; these problems.


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Prolonged convulsion 48. If the plasma sodium is less than 125 mmol/l and the convulsion is ongoing despite anticonvulsant

treatment, an infusion of 5 ml/kg of hypertonic saline should be given over one hour. No consensus achieved: strongly agree 61%

49. 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 0.5mmol/kg of 10% calcium gluconate should be given over 5 minutes (note that this precipitates if given simultaneously in the same IV line with ceftriaxone).


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50. If the plasma magnesium is less than 0.65 mmol/l and the convulsion is ongoing, an infusion of magnesium sulphate 5 mmol/kg should be given over one hour.


Post-convulsion state 51. After a convulsion has stopped, a child will often have a period of reduced consciousness, the

post-convulsion or “post-ictal” state, which will last for less than one hour in the majority of children.

a. During the first hour of the post-convulsion state, a detailed history and examination

should be performed, but if the capillary Blood Glucose is normal, and there are no other indications, other tests, including the core investigations may be deferred.


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b. After the first hour of the post-convulsion state, if the child has not recovered to a normal conscious level the core investigations should be performed.


52. Comments Speciality Comment Paediatric intensivist cannot be this prescriptive - will depend on context Neurologist

may be sedated for more than 1 hour if given midazolam and so reasonable to defer investigations if seen to be improving


The time to initiation of core tests may vary with the history and other elements of the physical examination


50: Magnesium dose differs massively to our local protocol

General paediatrics

The management of sodium, calcium and magnesium imbalance I would have to look up. Clear prescribing guidance for this in this guideline would be useful.

Emergency medicine

Not all epileptic children wake up after 1hour, if the seizure fits their known pattern and exam obs and BM ok they can be left longer to recover. If the episode is out of keeping with their known normal fit pattern/post ictal behaviour then yes do actively seek out an alternative diagnosis


Whilst I would definitely advise on treating low Na/ Ca/Mg the actual doses and way of doing so would be led by the PICU team


48, probably safe but differs from Guys formulary recommendation; guideline with doses would help 49 and 50. agree with concept but would need doses checked - again guideline doses with ease of access would help

Emergency medicine

Qu 52. Consider rephrasing to - after 1 hr if child's LOC is improving then core investigations do not need to be performed. If the child's LOC is not normal by 2 hrs or the GCS is not steadily improving by 1hr the core investigations should be performed

Metabolic

I agree with the correction but am uncertain of doses to be administered. Some core investigations should always be performed e.g. glucose. some can be deferred e.g. MRI brain scan


If a child is a known epileptic and had 2 doses of benzodiazepine to control seizures, he/she might not recover to normal conscious level within an hour.

Nursing

the history and examination should guide you as to whether investigations are required


Depends on whether buccal midazolam, rectal diazepam given as well as previous history (previous epileptic seizures with same characteristics).

Emergency medicine

1hr too long, given the time it takes to get investigation results back. Also depends if first or recurrent convulsion.

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Speciality Comment Paediatric neurology

Evidence that post ictal periods of >30 minutes suggest a remote symptomatic aetiology.

Nursing

51- depends if the child has had a previous convulsion, the length of convulsion or if they are febrile

Emergency medicine

WE would always do the core tests as part of the process of cannulating the child so these would almost invariable be sent off as part of that process.


154

No clinical cues to the cause 53. 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:

a. Thyroid Function Tests and Thyroid Antibodies, for Hashimoto's encephalitis No consensus achieved: strongly agree 57%

54. Comments Speciality Comment General paediatrics Only on specialist advice Paediatric intensivist

Specialist advice regarding availability of tests and interpretation of results should be part of this decision

Paediatric neurologist would consider a wider autoimmune investigation so include all General paediatrics This would not occur to me! Happy to do if appeared in the guideline.

have never seen it in a child Paediatric neurology thyroid peroxidase Antibodies Paediatric intensivist/neurologist

If antibody tests are to be done then more than this required or need considered e.g. GAD, NMDA etc.

Paediatric neurology Anti NMDA receptor antibodies Paediatric neurology MRI scan as well if it's not in core investigations

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Round 3 Prolonged Convulsions 55. If the plasma sodium is less than 125 mmol/l and the convulsion is ongoing despite anticonvulsant

treatment, 5 ml/kg of hypertonic saline should be given as a bolus. If the plasma sodium is less than 125 mmol/l and the convulsion is ongoing despite anticonvulsant treatment, 5 ml/kg of hypertonic saline should be given as a bolus.


56. Comments

Speciality Comment Metabolic I agree about the correction but would need to seek advice re the dose General Paeds I would agree that hypertonic saline is administered slowly over an

hour Paediatric Intensivist

I agree that hypertonic saline should be administered but the dose that I would use is different

General Paeds

I am uncertain about this and would have to look up. I would be worried about a bolus and would prefer an infusion.

Emergency medicine

If there is evidence of acute onset hyponatraemia (e.g. excessive water intake), Na replacement may be indicated at <125mmol/l, otherwise reserve hypertonic saline for Na <120 mmol/l

Emergency medicine General Paeds

I would have to double check the dose and rate It is important to check that potassium level is not very high in case of cortisol deficiency Plasma level below 120 is more concerned than 125

Emergency medicine what does anticonvulsant treatment mean: full protocol through to anaesthetic

Intercollegiate committee - Bristol

I think it’s important to state the strength of the hypertonic saline; there exists 3% (or 2.9%) and 5%. The dose in ml/kg should also be given with the concentration


You can argue over the dose but HTS should be given. A more often used dose in PICU might be 4 mls/kg of 3% saline. You also do need to quote the % HTS as 5 mls/kg of 30% HTS would not be a good idea!

Emergency medicine I would seek PICU support in the management of such a child before rapidly altering the Na

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Observations and Capillary Glucose 57. A child with a reduced conscious level and a blood glucose below 3 should have a hypoglycaemia

screen followed by immediate correction of blood sugar level. Consensus achieved: strongly agree 80%

58. In a child with a reduced conscious level and a blood glucose between 3 – 3.5, a laboratory

glucose should be checked, and consider treatment whilst awaiting the result. No consensus achieved: strongly agree 63%

59. Comments

Speciality Comment Paediatric intensivist In question 3 I would give glucose but not do the screen this could

delay treatment. Metabolic

If there is difficulty obtaining samples then the hypoglycaemic should be corrected before the screen.

General Paeds I feel 3-3.5 is always a 'grey' area, certainly if there are clinical concerns, correction is recommended

Emergency medicine

There is a regular discrepancy between the bedside and laboratory result so we would treat on the symptoms while we were awaiting the laboratory confirmation at that level.

Nursing We have a cut off of 2.6 for a hypoglycaemia screen Emergency medicine Treat (rather than consider treatment) whist awaiting the result. Metabolic

Age not given for pt- debate about bms in neonate a continue. Personal Practice in this case would be to do hypo screen and treat not wait for true glucose

Emergency medicine If GCS reduced, I would want to treat

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Response

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Speciality Comment Emergency medicine Again 3.0-3.5 will be unlikely to engender low GCS so other causes

should be sought Emergency medicine

There needs to be clarity about how long to wait trying to get blood samples before giving the glucose...1 minute, 5 minutes, and 15 minutes???

Intercollegiate committee - Bristol

Unlikely that a glucose of this level is the cause of the decreased conscious level. Importantly, something else will be the cause and getting distracted on a v mild level of hypoglycaemia may take focus away from the underlying cause.

Paediatric intensivist a BG of 3 or above is not abnormal Intensivist Depends how long the child has been unwell and how quickly the lab

result will come back. Emergency medicine

Question 3 - decision would be made on the actual BS and a case by case basis. I would consider a screen between 2.6 and 3.0

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Guideline for the management of a child aged 0‐18 years ......Analysis Round 1(part 1) Round 1...

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