Altered conscious state in children — formative SAQs

1. First 60 seconds

"This child is critically unwell with altered consciousness, shock and a purpuric rash. I call the senior paediatric and resuscitation teams now, name a leader, allocate roles, and bring age- and weight-appropriate equipment and monitoring. I secure the airway, give high-flow oxygen, support ventilation if ineffective, and treat shock while I begin the disability assessment. Stabilisation precedes diagnosis." ^[2]

2. Disability assessment

"I screen with AVPU: the child responds to Voice, which is below Alert, so I convert to an age-adapted Glasgow Coma Scale. I record best eye opening, best verbal response and best motor response separately, because the motor response and its trend are the most predictive components. I examine the pupils for size, equality and reactivity, assess posture and tone for lateralising signs, and time any seizure. I document the components and the total and reassess after each action." ^{[1] [2]}

3. Bedside glucose and DEFG

"I check a point-of-care glucose now because altered consciousness must always trigger DEFG: don't ever forget glucose. Hypoglycaemia can coexist with infection and is a reversible cause of brain injury. A dangerous low (around or below 3 mmol per litre in most children, using the local age-specific threshold) I correct immediately through the active age- and context-specific pathway, then recheck and investigate the cause. I confirm an unexpected result when feasible, but I never let confirmation delay treatment of a dangerous low." ^[4]

4. Raised intracranial pressure

"New pupillary asymmetry, dilation or unreactivity, abnormal decorticate or decerebrate posture, or a Cushing pattern of rising blood pressure with falling heart rate and irregular breathing signal raised intracranial pressure and impending herniation. My immediate response is to raise the head of the bed, keep the midline position, optimise oxygenation and control ventilation to avoid hypercapnia, because hypercapnia raises intracranial pressure, and arrange urgent neuroimaging and neurosurgical input. I do not perform a lumbar puncture until raised pressure is excluded and the child is stable." ^[9]