Introducing the Guideline on the Management of a Child with a Decreased Conscious Level: A Nationally Developed Evidence-based Guideline for Hospital Practitioners (The Paediatric Accident and Emergency Research Group, The University of Nottingham)
A child with decreased conscious level is a challenging medical problem to health care professionals. The present guideline was developed on an evidence based approach. It facilitate doctors in dealing the problem systemically. Easy to follow and detailed algorithms (Appendix A1-A7) were included to streamline the investigations and treatments. Latest literatures after the publication of the guideline were reviewed and no new evidence was found in subsequent reviews to justify any amendment of the original recommendations. Discussions on local adoptation are highlighted in the conclusion of the present paper.
Keyword : Adolescent; Child; Infant; Practice guideline; Unconsciousness
Children presenting with decreased conscious level can be due to a variety of reasons. It was found that about 30 children out of every 100,000 children per year would present in coma not caused by trauma. The overall mortality in this group of children could be up to 46%.1 While some causes are obvious, others could be much more obscure. The present evidence-based guideline was developed in 2005 to help front line doctors approach the problem systematically, recognise clinically important problems, investigate and treat them.2
The scope of the guideline confines to any child <18 years old, with a Glasgow coma score less than 15 or not being Alert (i.e. responding only to Voice, Pain or being Unresponsive) on the AVPU score.
This guideline should not be applied to preterm infants, children with known cause of their decreased conscious level and children with a chronic abnormal conscious level state.
The guideline mainly targets on the problems that can be identified and treated within the first hours of presenting to a hospital. Specific conditions or diseases which require specific treatment protocols are not covered in detail.
The purposes of our working group in reviewing the original guideline are:
I) To review the methodology of the guideline and the appraisal summary prepared by the Royal College of Paediatrics and Child Health, UK.3
II) To review latest literature after the guideline was published in 2005 and to see if any major changes are required.
III) To assess the applicability of the guideline to the local Hospital Authority hospitals.
I) Introduction to Methodology of the Original Guideline
The guideline was produced by the University of Nottingham, Paediatric Accident and Emergency Research Group which included medical and nursing professionals from paediatric emergency medicine, paediatric intensive care, metabolic medicine, neurology, general paediatrics, clinical chemistry, patient and lay representatives plus input from other stakeholder subspecialty societies or associations.
Literature was electronically and hand searched between March 2004 and July 2005 for a list of clinically relevant questions drawn up according to the scope and targeted clinical conditions the guideline aimed to answer. Papers selected were then appraised on methodological quality using critical appraisal checklist developed by the Scottish Intercollegiate Guideline Network4 and were given level of evidence according to the criteria developed by the Oxford Centre for Evidence-based Medicine.5
Papers which contributed to grade A and B recommendations were appraised by second member of the Guideline Development Group to ensure validity of the appraisal methodology.
When there was no published evidence found, a consensus approach was adopted. The guideline group utilised a large multi-professional Delphi panel for the Delphi Consensus process which enabled members of the panel to have their opinions registered anonymously, analysed, and then fed back to the same panel for further consideration. The whole panel results were reviewed. The group would help members to reconsider their initial position and panel members were at liberty to change their original opinion or their initial position. Consensus was aimed to achieve after one, two or three rounds of the Delphi panel discussion.6,7 The guideline recommendation and good practice points were thus based on agreement using evidence tables or the Delphi consensus results. Disagreement on wordings was settled by discussion or consultation with stakeholder groups. The draft guideline was then reviewed by all stakeholder groups, followed by an open forum discussion before it was finalised.
Formal appraisal process for the guideline were then performed by the Royal College of Pediatrics and Child Health and the British Association for Accident and Emergency Medicine in November 2005 using the AGREE instrument8 to assess the methodology quality followed by independent reviewers to examine the original research papers deriving the grade A and B recommendations in the guideline. Only minor regrading of the recommendation levels was made.3 An algorithm for the patient management was prepared (Appendix A1-A7).9
II) Review of the Latest Literature After the Guideline was Published in 2005
The guideline was originally planned to be reviewed 2 years after being published. Our working group thus initiated a simplified but systematic literature search for the latest evidence in the year 2005 and after.
Papers were searched electronically via the Hospital Authority eKG platform using database: Embase, Medline, and all All EBM Reviews - Cochrane DSR, ACP Journal Club, DARE, CCTR, CMR, HTA, and NHSEED and employing keywords: altered consciousness or consciousness disorder and the disease or clinical condition categories of the original guideline.2 Search was done around May 2009 for review articles and with patient age less than 18 year old and later search was repeated in early November 2009 to include additional keywords: meta analysis, systematic review, unconsciousness, transient loss of consciousness, coma, stupor, drowsiness, obtundation and delirium. Additional searches were done in 2010 on selected topics, especially on those with no Delphi consensus reached in the original guideline (investigation of borderline hypoglycaemia and management of raised intracranial pressure - fluid regime, use of mannitol or hypertonic saline and indication of invasive monitoring device)After the searches, systematic reviews or evidence based guidelines were identified on the topics of herpes simplex encephalitis,10 bacterial meningitis11-16 and meta analysis from Cochrane Database and Systemic Review on use of steroid in tuberculosis meningitis17,18 and use of mannitol for acute traumatic brain injury.19
III) The Applicability of the Guideline to the Local Hospital Authority Hospitals
Our working group acknowledges that certain recommendations of the original guideline may need local modifications or considerations.
Overall Guideline Review Summary
The present guideline together with the appraisal summary from Royal College of Paediatrics and Child Health and British Association for Emergency Medicine provide concise information and an easy to follow algorithm based on available evidence and consensus of a large representative group of different disciplines. Though the guideline was due for revision in 2007, we could not find new evidence (focused systematic search up to 2009) to justify any amendment of the grade A and B recommendation of the guideline. Additional evidences were noted on the use of steroid in tuberculous meningitis and meningitis likely of bacterial origin. Laboratory investigations for unclear causes of altered conscious are now streamlined in all Hospital Authority paediatric departments after local surveys and follow up actions. Recently, some has advocated including the investigation of poisoning, especially on carbon monoxide poisoning in the use of the guideline22 Individual departments are encouraged to explore and consolidate the consultation mechanism of subspecialists and the peri-arrest arrangement of investigations in their local setting if required.
(A1-A7) Algorithm. The management of a child (aged 0-18 years) with a decreased conscious level (http://www.nottingham.ac.uk/paediatric-guideline/Guideline algorithm.pdf (With kind permission from Dr Richard Bowker, lead author of the Paediatric Accident and Emergency Research Group which developed the guideline and algorithm).
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 - a nationally developed evidence-based guideline for hospital practitioners (The Paediatric Accident and Emergency Research Group), http://www.nottingham.ac.uk/paediatric-guideline/home2.htm; summary of recommendation: http://www.nottingham.ac.uk/paediatric-guideline/recdoc.pdf; full technical report: 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 in the hospital setting. Appraised by Royal College of Paediatrics and Child Health and British Association of Emergency Medicine. http://www.nottingham.ac.uk/paediatric-guideline/Guideline%20algorithm.pdf
4. Scottish Intercollegiate Guideline Network. SIGN 50: A guideline developers' handbook-Annex C. Critical appraisal: Notes and checklists. 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 development methods, and their use in clinical guideline development. Health Technol Assessment 1998;2:1-88.
7. The Delphi Consensus process. Guidleine for the management of 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 a decreased conscious level. http://www.nottingham.ac.uk/paediatric-guideline/Guideline%20algorithm.pdf
10. De Tiege X, RozenbergF, Heron B. The spectrum of herpes simplex encephalitis in children. Eur J Paediatr Neurol 2008;12:72-81.
11. Prasad K, Karlupia N, Kumar A. Treatment of bacterial meningitis: an overview of Cochrane systematic reviews. Resp Med 2009;103:945-59.
12. van de Beek D, Farrar JJ, de Gans J et al. Adjunctive dexamethasone in bacterial meningitis: a meta-analysis of individual 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, Erwin PJ, Tleyjeh IM. Corticosteroid administration and outcome of adolescents 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 Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2010;(9):CD004405. DOI:10.1002/14651858.CD004405.pub3
16. NICE clinical guideline 102 - Bacterial meningitis and meningococcal septicaemia Management of bacterial meningitis and meningococcal septicaemia in children and young people younger 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 tuberculous meningitis. Cochrane Database of Systematic Reviews 2009: Volume (4).
18. NICE Clinical Guideline 33 -Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 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 Systematic Reviews 2009:4.
20. Core laboratory investigations for the metabolic causes of reduced conscious level. Section 13. of summary of recommendation:
21. Guidance note on Perimortem / Postmortem Specimen Collection for Paediatric Patients suspected of unknown infectious diseases issued on 3 July 2009, Hospital Authority (Ref: HA 752/10/38/5/2).
22. Reece A, Cohn A, Heckmatt J. A suggested update for coma guideline. Arch Dis Child 2010;95:570-1.