Paeds · acute-care-resuscitation-and-toxicology
Altered conscious state in children
Also known as Altered mental status in children · Decreased conscious level in children · Paediatric coma assessment · AVPU and paediatric GCS · DEFG don't ever forget glucose
A fellowship approach to the child with an altered conscious state. Secure the airway with oxygen and ventilation, screen level of consciousness with AVPU and convert any response below Alert to an age-adapted Glasgow Coma Scale, check a bedside glucose immediately and correct a dangerous low now, treat an ongoing convulsion at five minutes, and keep infection, raised intracranial pressure, toxin, metabolic and safeguarding causes open while you escalate.
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Target exams
Red flags
- A child who is not Alert, or whose responsiveness is falling, needs an immediate disability assessment and a bedside glucose
- Unequal, dilated or unresponsive pupils with abnormal posture or a falling heart rate and rising blood pressure suggest raised intracranial pressure and impending herniation
- A dangerous low bedside glucose with altered consciousness must be corrected now, not after laboratory confirmation
- An ongoing convulsive seizure at five minutes is status epilepticus and activates first-line treatment
- A reduced conscious level with fever or a purpuric rash points to meningitis, meningococcaemia or encephalitis and needs time-critical antimicrobials
- An infant with altered behaviour, tone or feeding, or an inconsistent injury story, must keep non-accidental injury and safeguarding open
- Deteriorating consciousness despite treatment, or a need for airway or critical-care support unavailable locally, means call senior, PICU or retrieval now
Life stages
Care settings
Clinical exam formats
Board mappings
- Acute Care
- Current 2026 PREP curriculum — Learning Objective 2.2.1: Recognise, prioritise and manage an acutely ill infant, child or young person
- Current 2026 PREP curriculum — Learning Objective 2.2.3: Perform acute resuscitation and advanced life support
- Current 2026 PREP curriculum — Learning Objective 2.4.4: Assess and manage infants, children and young people with potential cardiac, respiratory or neurological emergencies or acute sepsis
- Current 2026 PREP curriculum — Learning Objective 2.4.5: Manage transfer of an unwell newborn, infant, child or young person
- Renewed curriculum for first-year trainees from 2027 — Learning goal 11: Acute care and procedures
- Renewed curriculum for first-year trainees from 2027 — Learning goal 17: Acute care
- Clinical Applications
- Medical Sciences
- Long Cases
- Short Cases
- 3. Professional skills and knowledge: Clinical procedures
- 4. Professional skills and knowledge: Patient management
- 6. Leadership and team working
- 7. Patient safety, including safe prescribing
- Neurodisability: Assesses and manages the comatose or acutely deteriorating child
- General Paediatrics: Resuscitates, stabilises and treats extremely unwell babies, children and young people, liaising with specialist teams, as necessary
- Foundation of Practice (FOP)
- Theory and Science (TAS)
- Applied Knowledge in Practice (AKP)
- Clinical
- History
- Communication
- Video
- General Pediatrics Content Outline — Domain 7: Emergency and Critical Care
- General Pediatrics Content Outline — Universal Task 1: Physiology and Pathophysiology
- General Pediatrics Content Outline — Universal Task 3: Diagnosis
- General Pediatrics Content Outline — Universal Task 4: Management and Treatment
- General Pediatrics EPA 7: Recognizing a Severely Ill Patient, Providing Initial Management, and Mobilizing Resources Needed for Continued Care
- Patient Care 3: Organize and Prioritize Patient Care
- Patient Care 4: Clinical Reasoning
- Patient Care 5: Patient Management
- Systems-Based Practice 1: Patient Safety
- Interpersonal and Communication Skills 2: Interprofessional and Team Communication
- Medical Expert
- Pediatrics: Foundations EPA #1 — Recognizing deteriorating and/or critically ill patients and initiating stabilization and management
- Pediatrics: Core EPA #2 — Resuscitating and stabilizing critically ill patients
Overview & Definition
Altered conscious state means any fall from the child's usual awareness of, and response to, their environment. It spans the wide gap between a child who is merely sleepy and a child who is deeply comatose, and it carries the same message in every case: the brain is failing, and the cause may kill or maim within minutes to hours. The job at the bedside is not to name the disease first; it is to protect the brain while you find out why. [1] [2]
Consciousness is the product of arousal, generated by the brainstem reticular activating system, and awareness, generated by the cerebral hemispheres. A fall in conscious level therefore points to one of two broad mechanisms: a diffuse disturbance of both hemispheres (metabolic, toxic, hypoxic, infective, post-ictal) or a focal lesion pressing on the brainstem (mass, haemorrhage, oedema, herniation). This single distinction drives almost every decision that follows, because a diffusely impaired brain is usually reversible, while a brain under pressure from a focal lesion can herniate and die. [2] [8]
[4] [5]The assessment runs inside the broader primary survey. Airway, breathing and circulation are assessed and supported first, because the most common cause of a falling conscious level in a sick child is upstream failure: hypoxia, hypercapnia or shock. Disability is then assessed with AVPU, an age-adapted Glasgow Coma Scale, the pupils, posture and tone, a timed seizure check, and the bedside glucose. A child with a reduced conscious level cannot protect their airway, so disability and airway protection advance together. [1] [2]
The disability assessment as a repeating loop
- 1
Secure A, B, C first
Protect and open the airway, give oxygen, support ventilation if breathing is ineffective, and treat shock, because upstream failure is the commonest cause of a falling conscious level.
- 2
Screen with AVPU
Record Alert, responds to Voice, responds to Pain or Unresponsive. Any response below Alert triggers a formal age-adapted Glasgow Coma Scale.
- 3
Examine the brain
Check pupil size and reactivity, posture and tone, movement, and time any seizure. Look for lateralising signs and for Cushing physiology.
- 4
Check glucose now
Measure a point-of-care glucose in every child with altered consciousness and correct a dangerous low immediately through the local age-specific pathway.
- 5
Reassess and escalate
Repeat the disability assessment after each action, watch the trend, and call senior, PICU or retrieval help before local support is exceeded.
References12ShowHide
- [1]Hoffmann F, Schmalhofer M, Lehner M, et al. Comparison of the AVPU Scale and the Pediatric GCS in Prehospital Setting Prehospital emergency care, 2016.PMID 26954262
- [2]Kirschen MP, Snyder M, Smith K, et al. Inter-Rater Reliability Between Critical Care Nurses Performing a Pediatric Modification to the Glasgow Coma Scale Pediatric critical care medicine, 2019.PMID 30946292
- [3]Czaikowski BL, Liang H, Stewart CT A pediatric FOUR score coma scale: interrater reliability and predictive validity Journal of neuroscience nursing, 2014.PMID 24556655
- [4]Faustino EV, Hirshberg EL, Bogue CW Hypoglycemia in critically ill children Journal of diabetes science and technology, 2012.PMID 22401322
- [5]Honarmand K, Sirimaturos M, Hirshberg EL, et al. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024 Critical care medicine, 2024.PMID 38240484
- [6]Chamberlain JM, Kapur J, Shinnar S, et al. Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial Lancet (London, England), 2020.PMID 32203691
- [7]Appleton RE, Rainford NE, Gamble C, et al. Levetiracetam as an alternative to phenytoin for second-line emergency treatment of children with convulsive status epilepticus: the EcLiPSE RCT Health technology assessment (Winchester, England), 2020.PMID 33190679
- [8]Cellucci T, Van Mater H, Graus F, et al. Clinical approach to the diagnosis of autoimmune encephalitis in the pediatric patient Neurology neuroimmunology and neuroinflammation, 2020.PMID 31953309
- [9]Dunger DB, Edge JA Predicting cerebral edema during diabetic ketoacidosis The New England journal of medicine, 2001.PMID 11172161
- [10]Chávez-Bueno S, McCracken GH Jr Bacterial meningitis in children Pediatric clinics of North America, 2005.PMID 15925663
- [11]Roy AA, Mankad K, Chong WK, et al. Neuroimaging of Non-Accidental Injury Current pediatric reviews, 2015.PMID 26219740
- [12]Gonzalez-Urdiales P, Kuppermann N, Dalziel SR, et al. Pediatric Intentional Self-poisoning Evaluated in the Emergency Department: An International Study Pediatric emergency care, 2021.PMID 32541402