Paediatrics: Altered level of consciousness: clinical assessment

Altered level of consciousness: clinical assessment

Initial examination

General examination can provide an explanation for the patient’s state.

General

·  Vital signs: make a note of the adequacy and rate and depth of respiration, the pulse rate and rhythm, BP, and body temperature.

·  Medic-Alert bracelet: search for a bracelet or tag, or other information that may indicate a longstanding medical problem.

·  Skin: examine for evidence of trauma, rash, petechiae, jaundice, and needle tracks.

·  Breath: check for odours of alcohol, ketones, hydrocarbons, or toxins.

Head and neck

·  Head: if the anterior fontanelle is patent, a tense fontanelle indicates raised ICP, whereas a sunken fontanelle suggests dehydration.

·  Nose and ears: leakage of blood or CSF; ‘raccoon eyes’ or Battle sign suggests basal skull fracture.

Pupils

·  Small (2–3mm) reactive pupils: suggest metabolic cause of coma.

·  Midsize (4–5mm) unreactive, midposition pupils: suggest midbrain lesion.

·  Pinpoint (1–2mm) pupils: indicate a pontine disorder, but are also commonly associated with opiates.

·  Unequal pupils with one fixed and dilated: suggest a brain disorder on the side of the dilated pupil.

·  Bilateral fixed dilated pupils: imply a poor prognosis, although similar pupils may be produced by mydriatics, barbiturate intoxication, and hypothermia.

Fundi

Examine for evidence of retinal haemorrhages and papilloedema.

After the ABCs, a focused neurological assessment is needed. Look for evidence of increased ICP and potential site of intracranial lesion.

Signs of raised ICP

The signs of raised ICP include:

·  Abnormal respiratory pattern.

·  Unequal or unreactive pupils.

·  Impaired or absent oculocephalic or oculovestibular responses.

·  Systemic hypertension, bradycardia.

·  Tense fontanelle.

·  Abnormal body posture or muscle flaccidity.