Paediatrics: Altered level of consciousness - Clinical assessment

2021-03-09 12:00 AM

The general examination can provide an explanation for the patient’s state.

Altered level of consciousness: clinical assessment

Initial examination

A general examination can provide an explanation for the patient’s state.


  • Vital signs: make a note of the adequacy and rate and depth of respiration, the pulse rate and rhythm, BP, and body temperature.
  • Medic-Alert bracelet: search for a bracelet or tag, or other information that may indicate a longstanding medical problem.
  • Skin: examine for evidence of trauma, rash, petechiae, jaundice, and needle tracks.
  • Breath: check for odours of alcohol, ketones, hydrocarbons, or toxins.

Head and neck

  • Head: if the anterior fontanelle is patent, a tense fontanelle indicates raised ICP, whereas a sunken fontanelle suggests dehydration.
  • Nose and ears: leakage of blood or CSF; ‘raccoon eyes’ or Battle sign suggests basal skull fracture.


  • Small (2–3mm)reactive pupils: suggest the metabolic cause of coma.
  • Midsize (4–5mm)unreactive, mid-position pupils suggest midbrain lesion.
  • Pinpoint (1–2mm)pupils indicate a pontine disorder but are also commonly associated with opiates.
  • Unequal pupils with one fixed and dilated: suggest a brain disorder on the side of the dilated pupil.
  • Bilateral fixed dilated pupils: imply a poor prognosis, although similar pupils may be produced by mydriatics, barbiturate intoxication, and hypothermia.


Examine for evidence of retinal haemorrhages and papilloedema.

After the ABCs, a focused neurological assessment is needed. Look for evidence of increased ICP and a potential site of an intracranial lesion.

Signs of raised ICP

The signs of raised ICP include:

  • Abnormal respiratory pattern.
  • Unequal or unreactive pupils.
  • Impaired or absent oculocephalic or oculovestibular responses.
  • Systemic hypertension, bradycardia.
  • Tense fontanelle
  • Abnormal body posture or muscle flaccidity.