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Friday, 14 February 2014

Reduced Consciousness in Children

The unconscious child has some specific causes which we have looked at in more detail. There are also some more general causes, covered thoroughly on enlightenme. There are some specific guidelines from Nottingham that are universally accepted.


History
- Clues to dehydration
- Consanguinous relationship should be sought.

Specific Examination
- The child should be examined to look for physical clues which may suggest an underlying metabolic problem, such as dysmorphism, hypotonia, failure to thrive and enlarged liver.
- Look for herpetic lesions
- Paediatric GCS


Investigations
- Blood gas: pH, pCO2, bicarbonate and lactate may provide useful information in cases of shock, sepsis, trauma, respiratory distress, or suspected acid-base imbalance.
- If sepsis suspected: urinalysis, full blood count: haemoglobin, white cell count and differential, and platelet count; blood culture (meningococcal pcr depending on clinical presentation), CRP.
http://adc.bmj.com/content/93/2/183.1.extract
- Metabolic-specific cases: Venous/arterial blood gas, glucose, urinary ketones, LFTs, serum ammonia, U+Es (consider if BM <2.6mmol/L)
- Overdose cases: Plasma, serum and urine to be saved for later analysis of specific agents e.g. opiates, tricyclics

Management
ABCDE
Consider trial of naloxone


High ammonia levels (>200micromol/L) are neurotoxic. Lower levels with a sodium benzoate infusion.

If meningitis is suspected, treating with steroids (dexamethasone 0.15 mg/kg prior to first dose of antibiotics) reduces profound hearing loss if the causative agent is Haemophilus influenza type B (HIB) and less so in cases of meningococcal or streptococcal infection.

Herpes simplex encephalitis should be suspected in a child with a decreased consciousness and focal neurological signs, fluctuating consciousness, contact with herpetic lesions.
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