Paediatrics: Altered level of consciousness - Clinical assessment
The general examination can provide an explanation for the patient’s state.
Altered level of consciousness: clinical assessment
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.