HK J Paediatr (new series) 2013;18:105-116

Introducing the Guideline on the Management of a Child witha Decreased Conscious Level: A Nationally Developed

Evidence-based Guideline for Hospital Practitioners(The Paediatric Accident and Emergency Research Group,

The University of Nottingham)

KC CHAN, NKC TSE, SY LAM, LCK LEUNG, MC YAM, KL SIU, DCW CHAN, SM TAI, AWY YUNG

Abstract A child with decreased conscious level is a challenging medical problem to health care professionals. Thepresent guideline was developed on an evidence based approach. It facilitate doctors in dealing the problemsystemically. Easy to follow and detailed algorithms (Appendix A1-A7) were included to streamline theinvestigations and treatments. Latest literatures after the publication of the guideline were reviewed andno new evidence was found in subsequent reviews to justify any amendment of the originalrecommendations. Discussions on local adoptation are highlighted in the conclusion of the present paper.

Key words Adolescent; Child; Infant; Practice guideline; Unconsciousness

Department of Paediatrics and Adolescent Medicine, Alice HoMiu Ling Nethersole Hospital, 11 Chuen On Road, Tai Po,N.T., Hong Kong, China

KC CHAN FHKCPaed, FRCP(Edin), FRCPCH

Department of Paediatrics and Adolescent Medicine, PrincessMargaret Hospital, 2-10 Princess Margaret Hospital, Lai ChiKok, Kowloon, Hong Kong, China

NKC TSE MBBS, FHKAM, FHKCPaed

Department of Paediatrics and Adolescent Medicine, Tuen MunHospital, 23 Tsing Chung Koon Road, Tuen Mun, N.T., HongKong, China

SY LAM MBBS(HK), MRCP(UK), FHKAM(Paed)

Department of Paediatrics and Adolescent Medicine, KwongWah Hospital, 25 Waterloo Road, Kowloon, Hong Kong, China

LCK LEUNG FHKCPaed, FHKAM(Paed), FRCP (Edin)

Department of Paediatrics and Adolescent Medicine, Princeof Wales Hospital, 30-32 Ngan Shing Street, Shatin, N.T., HongKong, China

MC YAM MBChB(CUHK), FHKAM(Paed)

Department of Paediatrics and Adolescent Medicine, QueenElizabeth Hospital, 30 Gascoigne Road, Kowloon, Hong Kong,China

KL SIU MBBS(HK), FHKAM(Paed), FHKAM(Paed)

Department of Paediatrics and Adolescent Medicine, UnitedChristian Hospital, 130 Hip Wo Street, Kwun Tong, Kowloon,Hong Kong, China

DCW CHAN MBBS(HK), FHKAM(Paed), FHKCPaed

Department of Paediatrics and Adolescent Medicine, PamelaYoude Nethersole Eastern Hospital, 3 Lok Man Road, ChaiWan, Hong Kong, China

SM TAI MBChB(CUHK), FHKAM(Paed), FHKCPaed

Duchess of Kent Children Hospital, 12 Sandy Bay Road,Pokfulam, Hong Kong, China

AWY YUNG MBBS, MRCP, FHKAM

Correspondence to: Dr KC CHAN

Received August 24, 2012

*Guideline reviewed by the Working Group on Guideline and Evidence Based Practice,

QA Subcommittee, COC Paediatrics, Hospital Authority, Hong Kong

Chan et al 106

Background

Children presenting with decreased conscious level canbe due to a variety of reasons. It was found that about 30children out of every 100,000 children per year wouldpresent in coma not caused by trauma. The overall mortalityin this group of children could be up to 46%.1 While somecauses are obvious, others could be much more obscure.The present evidence-based guideline was developed in2005 to help front line doctors approach the problemsystematically, recognise clinically important problems,investigate and treat them.2

The scope of the guideline confines to any child

Introducing UK Guideline on Unconscious Child107

II) Review of the Latest Literature After theGuideline was Published in 2005

The guideline was originally planned to be reviewed 2years after being published. Our working group thusinitiated a simplified but systematic literature search forthe latest evidence in the year 2005 and after.

Papers were searched electronically via the HospitalAuthority eKG platform using database: Embase, Medline,and all All EBM Reviews Cochrane DSR, ACP JournalClub, DARE, CCTR, CMR, HTA, and NHSEED andemploying keywords: al tered consciousness orconsciousness disorder and the disease or clinical conditioncategories of the original guideline.2 Search was donearound May 2009 for review articles and with patient ageless than 18 year old and later search was repeated in earlyNovember 2009 to include additional keywords: metaanalysis, systematic review, unconsciousness, transient lossof consciousness, coma, stupor, drowsiness, obtundationand delirium. Additional searches were done in 2010 onselected topics, especially on those with no Delphiconsensus reached in the original guideline (investigationof borderline hypoglycaemia and management of raisedintracranial pressure fluid regime, use of mannitol orhypertonic saline and indication of invasive monitoringdevice)

After the searches, systematic reviews or evidence basedguidelines were identified on the topics of herpes simplexencephalitis,10 bacterial meningitis11-16 and meta analysisfrom Cochrane Database and Systemic Review on use ofsteroid in tuberculosis meningitis17,18 and use of mannitolfor acute traumatic brain injury.19

a) Herpes simplex encephalitis A review article by DeTiege et al was published in 2008.10 The content of thereview was in line with the recommendations made bythe Guideline on Herpes simplex encephalitis.

b) Bacterial meningitis The source articles of the reviewpublished in 2009 by Prasad et al11 concerning the useof corticosteroid were already included in the referencelist of the original guideline. Another meta-analysis ofindividual patient data extracted from recentrandomised, double-blind, placebo-controlled trials waspublished in March 2010.12 Though adjunctivedexamethasone treatment does not seem to significantlyreduce death, dexamethasone seemed to reduce hearing

loss among survivors.12,13 This is line with the findingof another meta-analysis14 and the latest review fromthe Cochrane collaboration review finding thatcorticosteroid dexamethasone leads to a reduction inhearing loss.15 The recent NICE guideline16 alsoconfirmed the beneficial effect of early (before or withthe first dose antibiotics) steroid treatment on long termneurological sequelae. The beneficial effect on reducingsevere hearing loss can also be observed when steroidis given shortly after the first dose of antibiotics (5 RCTsinvolving 501 children, RR 0.29, 95% CI 0.14 to 0.63,p = 0.002). A steroid regime was thus proposed in theNICE guideline for patients older than 3 months oldwith high likelihood of bacterial meningitis.

c) Use of steroid in tuberculous meningitis The originalguideline does not cover the treatment of the tuberculousmeningitis. In a systematic review by Prasad et al17

involving seven trials, 1140 participants (including 411deaths) with all having used dexamethasone orprednisolone, corticosteroids reduced the risk of death(RR 0.78, 95% CI 0.67 to 0.91). Data on disablingresidual neurological deficit from three trials showedthat corticosteroids reduce the risk of death or disablingresidual neurological deficit (RR 0.82, 95% CI 0.70 to0.97). Hence, corticosteroids are recommended in HIV-negative people with tuberculous meningitis to reducedeath and disabling residual neurological deficit. Theuse of steroid with concomitant anti-tuberculoustreatment is included in the NICE guideline.18

d) Use of mannitol for acute traumatic brain injury In the review by Wakai and Robert,19 four trialspublished in 1984 to 2003 were reviewed but there wasno articles included after the present guideline waspublished. Thus there is no new reliable evidence tomake recommendations on the use of mannitol in themanagement of patients with traumatic brain injury.During the literature search, latest articles possiblyrelated to guideline grade A or B recommendations werethen appraised on their methodological quality similarto the approach as stipulated in the original guidelineand discussed in the Working group meetings. Afterrounds of discussions, it was finally concluded that thereare no new evidence to justify any amendment of theoriginal grade A and B recommendations of theguideline.

Chan et al 108

III) The Applicability of the Guideline to theLocal Hospital Authority Hospitals

Our working group acknowledges that certainrecommendations of the original guideline may need localmodifications or considerations.a) Core laboratory investigations for metabolic causes of

reduced conscious level and hypoglycaemia in childrenwith no other clear explanation.20

Local surveys were done covering all HospitalAuthority paediatric departments with emergencyadmissions. All the core investigations are availablewithin their own cluster hospitals. However, some ofthe investigations for hypoglycaemia are not availablelocally, like plasma insulin, growth hormone, freefatty acid, plasma beta-hydroxybutyrate, acyl-carnitine profile and urine organic acid. After somefollow up arrangements, they can now be accessedthrough the two university hospitals (Prince of Walesand Queen Mary Hospitals) or through PrincessMargaret and Queen Elizabeth Hospitals.

b) Service arrangements like timing of consultation ofexperienced paediatrician, paediatric subspecialist orspecialist of other discipline. While recruiting subspecialist or experts in other

fields early in the patient care process is the trend,our working group found these service arrangementrecommendation being beyond the scope of ourworking group review. Differences in medicalsystems and variations in the sett ings andorganisations of individual hospitals may imply somelocal adaptation being required before adoption ofthese recommendations.

c) Conditions identified in the guideline requiringmanagement protocol agreed at a local level. Specific conditions like the management of raised

intracranial pressure are recommended to have localguidelines. On the other hand, though the guidelinerecommends the NICE guideline for the managementof diabetes ketoacidosis, it is envisaged that therecould also be minor variation among localdepartments in fine tuning the management of thediabetes ketoacidosis patients.

d) Peri-arrest arrangement or investigations taken at postmortem. The original guideline has grade D recommendations

on certain tests to be performed based on grade 5evidence (expert opinions). While these are usefulreferences, it is worth noting that Hospital Authorityhas also issued a Guidance note on Perimortem /Postmortem Specimen Collection for PaediatricPatients suspected of unknown infectious diseases inJuly 2009.21 In the local guidance notes, tests fortoxicology and inborn errors of metabolism are alsoincluded. Individual hospitals are advised to reviewthe local guidance note and to liaise with the localpathology department accordingly.

Overall Guideline Review Summary

The present guideline together with the appraisalsummary from Royal College of Paediatrics and ChildHealth and British Association for Emergency Medicineprovide concise information and an easy to follow algorithmbased on available evidence and consensus of a largerepresentative group of different disciplines. Though theguideline was due for revision in 2007, we could not findnew evidence (focused systematic search up to 2009)to justify any amendment of the grade A and Brecommendation of the guideline. Additional evidenceswere noted on the use of steroid in tuberculous meningitisand meningitis likely of bacterial origin. Laboratoryinvestigations for unclear causes of altered conscious arenow streamlined in all Hospital Authority paediatricdepartments after local surveys and follow up actions.Recently, some has advocated including the investigationof poisoning, especially on carbon monoxide poisoning inthe use of the guideline22 Individual departments areencouraged to explore and consolidate the consultationmechanism of subspecialists and the peri-arrest arrangementof investigations in their local setting if required.

Introducing UK Guideline on Unconscious Child109

References

1. Wong CP, Forsyth RJ, Kelly TP, Eyre JA. Incidence, aetiology,and outcome of non-traumatic coma: a population base study.Arch Dis Child 2001;84:193-9.

2. The management of a child with a decreased conscious level - anationally developed evidence-based guideline for hospitalpractitioners (The Paediatric Accident and Emergency ResearchGroup), http://www.nottingham.ac.uk/paediatric-guideline/home2.htm; summary of recommendation: http://www.nottingham.ac.uk/paediatric-guideline/recdoc.pdf; full technicalreport: http://www.nottingham.ac.uk/paediatric-guideline/Tecdoc.pdf

3. The management of a child with a decreased conscious level.An evidence based guideline for health professionals based inthe hospital setting. Appraised by Royal College of Paediatricsand Child Health and British Association of EmergencyMedicine. http://www.nottingham.ac.uk/paediatric-guideline/Guideline%20algorithm.pdf

4. Scottish Intercollegiate Guideline Network. SIGN 50: A guidelinedevelopers' handbook-Annex C. Critical appraisal: Notes andchecklists. SIGN 2001. www.sign.ac.uk

5. Philips B, Ball C, Sackett D, et al. Oxford Centre for Evidence-Based Medicine Levels of evidence, 1998. www.cebm.net

6. Murphy M, Black N, Lamping D, et al. Consensus developmentmethods, and their use in clinical guideline development. HealthTechnol Assessment 1998;2:1-88.

7. The Delphi Consensus process. Guidleine for the managementof a chid aged 0-18 years with a decreased conscious level.Appendix B. http://www.nottingham.ac.uk/paediatric-guideline/B.pdf; http://www.nottingham.ac.uk/paediatric-guideline/delphi.htm

8. Appraisal of Guidelines for Research and Evaluation(AGREE) Instrument. The AGREE collaboration, 2001.www.agreecollaboration.org

9. Algorithm. The management of a child (aged 9-18 years) with adecreased conscious level. http://www.nottingham.ac.uk/paediatric-guideline/Guideline%20algorithm.pdf

10. De Tiege X, RozenbergF, Heron B. The spectrum of herpessimplex encephalitis in children. Eur J Paediatr Neurol 2008;12:72-81.

11. Prasad K, Karlupia N, Kumar A. Treatment of bacterialmeningitis: an overview of Cochrane systematic reviews. RespMed 2009;103:945-59.

12. van de Beek D, Farrar JJ, de Gans J et al. Adjunctivedexamethasone in bacterial meningitis: a meta-analysis ofindividual patient data. Lancet Neurol 2010:9:254-63.

13. McIntyre P. Adjunctive dexamethasone in bacterial meningitis:

does value depend on clinical setting? Lancet Neurol 2010:9:229-31.

14. Assiri AM, Alasmari FA, Zimmerman VA, Baddour LM, ErwinPJ, Tleyjeh IM. Corticosteroid administration and outcome ofadolescents and adults with acute bacterial meningitis: a meta-analysis. Mayo Clin Proc 2009;84:403-9.

15. Brouwer MC, McIntyre P, de Gans J, Prasad K, van de BeekD. Corticosteroids for acute bacterial meningitis. CochraneDatabase Syst Rev 2010;(9):CD004405. DOI:10.1002/14651858.CD004405.pub3

16. NICE clinical guideline 102 - Bacterial meningitis andmeningococcal septicaemia Management of bacterial meningitisand meningococcal septicaemia in children and young peopleyounger than 16 years in primary and secondary care. Issue date:June 2010, revised September 2010. http://www.nice.org.uk/nicemedia/live/13027/49339/49339.pdf

17. Prasad K, Singh MB. Corticosteroids for managing tuberculousmeningitis. Cochrane Database of Systematic Reviews 2009:Volume (4).

18. NICE Clinical Guideline 33 -Tuberculosis: clinical diagnosis andmanagement of tuberculosis, and measures for its prevention andcontrol. Issue date March 2006.

19. Wakai A, Roberts IG. Mannitol for acute traumatic brain injury.EBM Reviews - Cochrane Database of Systematic Reviews.00075320-100000000-00509 Cochrane Database of SystematicReviews 2009:4.

20. Core laboratory investigations for the metabolic causes of reducedconscious level. Section 13. of summary of recommendation:http://www.nottingham.ac.uk/paediatric-guideline/recdoc.pdf

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22. Reece A, Cohn A, Heckmatt J. A suggested update for comaguideline. Arch Dis Child 2010;95:570-1.

Appendix

(A1-A7) Algorithm. The management of a child (aged0-18 years) with a decreased conscious level (http://www.nottingham.ac.uk/paediatric-guideline/Guideline%20algorithm.pdf (With kind permission from Dr RichardBowker, lead author of the Paediatric Accident andEmergency Research Group which developed the guidelineand algorithm).

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Appendix A1 Guideline for the management of a child aged 0-18 years with a decreased conscious level.

Introducing UK Guideline on Unconscious Child111

Appendix A2 Algorithm for the management of a child aged 0-18 years with a decreased conscious level.

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Appendix A3 Indentify all problems.

Introducing UK Guideline on Unconscious Child113

Appendix A4 Indentify all problems (continued from A3).

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Appendix A5 Management of all 16 identified problems.

Introducing UK Guideline on Unconscious Child115

Appendix A6 Management of all 16 indentified problems (continued from A5).

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Appendix A7 Management of all 16 indentified problems (continued from A5 & A6).