Regional Guidelines For The Assessment of Level of Consciousness in Children

 

Paediatric Critical Care Network 

Regional Guidelines for the Assessment of Level of Consciousness in Children

Date: June 2009 Review Date: June 2011 Lead Author: Dr Mark Darowski

 

Members of the Advisory Group Mark Darowski (Chair), Paediatric Critical Care Network Lead Clinician/Consu Clinician/Consultant ltant Intensivist, Leeds PCT/Leeds Teaching Hospitals NHS Trust Michael Clarke, Consultant Paediatric Neurologist, Leeds Teaching Hospitals NHS Trust Fraser Scott, Consultant Consultant Paediatrician, Mid-Yorkshire Hospitals NHS Trust Jo Smith, Lecturer in Children Health Nursing, Nursing, School of Healthcare, Healthcare, University of Leeds Michelle Milner, Children's Network Manager, Leeds PCT Sarah Fletcher, Matron, Children's Services, Leeds Teaching Hospitals NHS Trust Liz Clancy, Paediatric Nurse Practitioner, Calderdale & Huddersfield Huddersfield Foundation Trust Linda Daniel, Paediatric Critical Care Network Educator, Leeds PCT Heather McClelland , Nurse Consultant - Emergency Care, Calderdale & Huddersfield NHS

Foundation Trust Jake Timothy, Consultant Neurosurgeon, Leeds Teaching Hospitals NHS Trust Mick Stone, Charge Nurse, Neurosurgical Neurosurgical Intensive Care Unit, Leeds Teaching Hospitals NHS Trust

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ASSESSMENT OF LEVEL OF CONSCIOUSNESS IN CHILDREN Target audience  All nursing and medical staff who, as part of their normal duties, care for children (0-16 years) with impaired levels of consciousness. These include staff working in children’s wards, PICUs, A&E departments, adult wards and ICUs, and theatre recovery areas caring for f or children. Why perform the assessment? assessment? To determine a patient’s level of consciousness consciousness and to monitor changes in their condition.  Abnormal baseline baseline values or or changes in values values should trigger trigger actions by staff. staff. Who performs the assessme assessment? nt? Staff trained in the performance of the assessment. Trained staff must understand the significance of the assessment in relation to changing levels of  consciousness consciousn ess and the importance of accurate documentation and communication of any changes in the child’s condition. Which children require neurological assessment?  Any child who Is suspected of having an altered or changing level of consciousness consciousness that is not associated with normal recovery from anaesthesi anaesthesia a or sedation. Has behavioral changes, disorientation or confusion Has a condition associated with potential neurological impairmen impairmentt (Appendix 1). •

•

•

How often is a child assessed? Initial assessment should be performed on any child meeting the criteria above. The frequency of neurological assessment depends on the child’s condition and will be agreed between medical and nursing staff taking account of local protocols. The frequency of assessment must be prescribed and recorded on the chart by the admitting doctor or as described in local guidelines. guidelines. NICE guidelines guidelines for the management management of patients patients with head injury sugg suggest est that observati observations ons should sho uld be pe perfo rforme rmed d an and d record recorded ed on a ha halflf-ho hourl urly y bas basis is until until GCS equal equal to 15 ha has s been been achieved. The minimum frequency of observations for head injured patients with GCS equal to 15 should be as follows, starting after the initial assessment in the emergency department: - half-hourly for 2 hours; - then 1-hourly for 4 hours; - then 2-hourly thereafter. Should a patient with GCS equal to 15 deteriorate at any time after the t he initial 2-hour period, observations should revert to half-hourly and follow the original frequency schedule. In other situations, the agreed frequency may be half hourly, or more frequently, depending  on the child’s condition.

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What are the components of neurological assessment? assessment? Neurological assessment includes the following components. • • • • • •

• •

James’ Modification of the Glasgow Coma Scale* (GCS) Pupillary responses Posture  Abnormal eye movement movement or position position Motor power in limbs (weakness) Heart He art rate, rate, bl blood ood pressu pressure, re, respir respirato atory ry rate/r rate/rhyt hythm, hm, tempe temperat rature ure an and d SpO2 SpO2 if GCS is abnormal Palpation of fontanelle in infants Recordin Reco rding g of other other significant significant events: events: seizures seizures,, episodes episodes of vomiting, vomiting, complaints complaints of  head/neck pain or visual disturbance, difficulty in swallowing, CSF leak from ear or nose.

* The The terms Scale and Score are both commonly used. Throughout this document we have chosen to use Scale.

ASSESSMENT Before performing a neurological assessment check ABC. 1. The modified modified Glasgow Coma Scale Scale The level of consciousness is assessed by the patients’ ability to perform 3 activities, which are scored individually individually as detailed in table 1. 1. Eye op opening 2. Verb Verbal al re resp spon onse se 3. Moto Motorr re resp spon onse se For younger children the responses expected should reflect their stage of development development (Table 1). How do I perform the assessment? It is usually helpful to include the child’s parent or main carer in the assessment process, e.g. in speaking to the child in their own language or when trying to wake them. However the assessment must be performed objectively and promptly. A painful stimulus may need to be applied and carers forewarned. The following steps enable the GCS to be assessed quickly and with the least possible disturbance disturbance to the child. In order to this the different elements of the GCS need to be assessed simultaneously (Table 2). Be aware of the t he good practice points described in Box 1 below:

Box 1. Good practice points. •

•

•

 A sleeping child child should always always  be woken for neurological neurological observations It is essent essential ial that that the child child’s ’s no norma rmall neurol neurologi ogical cal status status and develo developme pmenta ntall level level is established, establishe d, by involving carers, if they are present.  At any patient handover (ward transfer, shift change etc) the observations observations must be performed by the by both nurses together to ensure consistency.

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Table 1: Overview of Child’s Glasgow Coma Scale (Kirkham et al 2008) Child’s Glasgow Coma Scale >5yr Eye opening E4 E3 E2 E1 C Verbal V5

9mo) Withdraws from nailbed pain Flexion to supraorbital pain Extension to supraorbital pain No response to supraorbital pain Child is paralysed – muscle relaxants or spinal injury

V4

Orientated

Motor 

M4 M3 M2 M1 P

Normal spontaneous movements Withdraws to touch (5y the responses are similar to the adult Glasgow coma scale. Pain should be made by pressing hard on the supraorbital notch (beneath medial end of eyebrow) with your  thumb, except for Motor score 4, which is tested by pressing hard on the flat finger nail surface with the barrel of a pencil. If there is facial trauma or swelling that prevents you form using the supraorbital ridge or there is doubt about the response to the supraorbital stimulus, then pinch the earlobe as an alternative stimulus.

Score the best response if unclear or asymmetrical. If in doubt repeat after 5 minutes and ask for a second opinion. Score as usual in the presence of possibly sedating drugs. Plot scores over time on a suitable chart.

 

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Step 1  1  If the child’s eyes are open (E4), the carer or nurse/doctor should talk to the child in a language familiar to the child and appropriate for their age. Observe the child’s verbal and motor response e.g. verbal: babbling for a child less than 9months •

•

any words from 12months any sentences from 2years orientation in place and time from 5years

• •

motor: waving bye for a child aged 9–12 months putting a hairbrush to the head for a child aged 12–15months pointing to body parts for a child aged 15–24months

• • •

Decide with the carer whether any verbal response obtained is appropriate for the child’s usual ability (V5) or less than t han the child’s usual ability (V4). If a child appears to understand what is said to them, even if tthey hey are not speaking, ask the child to obey a simple command, e.g. squeeze the carer’s finger or squeeze his eyes shut (M6). In infants and children with developmental delay, watch for normal spontaneous movement (M6). If the child does not have any spontaneous speech or eye opening, proceed to Step 2. Step 2 If the child’s eyes are closed, talk to them and observe whether their eyes open in response to a verbal stimulus (E3). If the child opens their eyes, observe whether they appear to recognize the carer and understand what is said. If this is the case, elicit a verbal and motor responses as for Step 1. If there is no attempt to verbalise or move when the assessor talks or gently touches the child, proceed to Step 3. Step 3

3.1  A painful stimulus must be applied to complete the assessment. Supraorbital pressure is the stimulus of choice (Box 2). Explain to the carer that you are going to press on the child’s forehead to see if they will respond to pain.

Box 2. Applying the stimulus •

• •

•

To apply supraorbital pressure, press firmly on the supra-orbital notch (beneath the medial end of the eyebrow) with your thumb.  Apply nailbed nailbed pressure pressure tested by pressing hard on the flat finger nail surface with the barrel of a pencil. If there are facial fractures or severe swelling involving the supraorbital ridge, pinch the ear lobe to provide an alternative stimulus. If you are not confident about supra-orbital pressure, or nailbed pressure, try the technique on yourself  first: press hard enough to elicit a very focal sharp pain. This feels different to the pressing feeling and

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Observe and document the child’s response: 1. The The eye eyes s ope open n (E3 (E3) 2. Cr Crie ies s or uses inapp inappro ropr pria iate te wo word rds( s(V3 V3); ); or moans moans or make makes s inco incomp mpre rehe hens nsib ible le sounds(V2) 3. Move Moves s thei theirr arm arms: s:  – Above the clavicle (with supraorbital pressure), or to remove the painful stimulus if   –  –  –

another stimulus used (localization to pain, M5) Below the clavicle clavicleisbut flexing at at the elbow (flexion (flex ion to pain, M3) Fig 1 Below the clavicle without flexion but with rotation at the shoulder (extension, M2) Fig 2 No movement movement (M1)

Fig 1 Decorticate Posture results from damage to one or both corticospinal tracts. In this posture, the arms are adducted and flexed, with the wrists and fingers flexed on the chest. The legs are stiffly extended and internally rotated, with plantar flexion of the feet.

Fig 2 Decerebrate posture results from damage to the upper brain stem. In this posture, the arms and adducted  and extended, with the wrists pronated and the fingers flexed. The legs are stiffly extended, with plantar flexion of the feet.

If the child does not move following the initial application of a painful stimulus, press more firmly (as hard as you can) and observe whether there is movement of any body part, including the face (grimace). An absence of body movement in a child whose face moves may suggest a spinal cord injury. If the child flexes but does not localize apply nail bed and pressure observe whether or not the child moves the finger away (withdrawal (withdrawal to pain, M4). Flexion is assessed in the arms; do not use a limb with an obvious injury. If there is asymmetry when assessing record the best response. Record and report asymmetrical movement move ment,, which which could could indi indicate cate impending impending uncal uncal herniati herniation, on, particul particularly arly if the pupil size and response to light is also asymmetrical asymmetrical..

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3.2 When assessing an infant touch and stroke the child on the hand and forearm and note any withdrawall to touch (M5). withdrawa 3.3 If you cannot feel one or other supra-orbital notch, e.g. because of traumatic facial swelling, apply an earlobe pinch. Score localizes to pain (M5) if the child brings the contra-lateral (opposite) arm partly across the body to dislodge the pain or makes a complex purposeful manoeuvre manoeuvre to remove the pain, not just a simple withdrawal (M4). Observe the eye opening and verbal responses to pain at the same time. When assessing infants the eye opening score is often E1 (none), even when verbal and motor  scores are high, e.g. V4, V5, M5, or M6. Step 4 Document the date and time at which the observations were performed. Write down the response observed for eye opening, verbal response response,, and motor response. If there is asymmetry of the motor or eye opening response, write down the better side. The eye opening, verbal and motor responses are always assessed and communicated separately; an aggregate score can mask important changes.  A decrease of 1 point point in the motor score score or an overall overall deterioration deterioration of two points is considered considered significant.  A summated score score can provide a q quick uick guide to a child’s child’s level of consciousne consciousness. ss. A total score of  15 (E4,V5,M6) represents an alert, orientated patient. A score of 8 represents severely impaired consciousness consciousn ess and may require airway support. A score of 3 indicates a deep coma.

Intubated children For intubated patients, score eye opening and motor responses as above and write down T (for  ‘tube’) for the verbal score. Many paediatric intensive care units have adopted the grimace scale in place of the verbal scale. Although there is good inter-observer agreement it has not yet been assessed as a tool for the prediction of outcome. Paralysed children If the child is paralysed (muscle relaxants or spinal cord injury) record P for motor response.

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2. How do I measure pupillary responses? Responses should be elicited using a bright pen torch (not an opthalmoscope, otoscope or  laryngoscope), in low ambient lighting, if possible. Allow 5 seconds before testing the opposite eye to allow for recovery of the consensual light reflex. Both eyes should be central looking forward. Deviation may be normal (squint -ask the family). New deviation may be the sign of significant disease. • • •

Open both eyes. Observe pupils without stimulation for size and equality Shine light into each eye in turn. Light in one eye should cause simultaneous constriction of both pupils. When light is withdrawn, both pupils should dilate simultaneously. 



The responses of each pupil are described in terms of  Size – recorded as pinpoint, small, moderate or dilated Reactivity to light - recorded as brisk (record as B), no response/fixed (F), sluggish (S) or closed (C) Equality - of size and of response •

•

•

Pupillary responses may be affected by medication. Opiates cause constriction. Eye drops given before ophthalmologic ophthalmologic examination and adrenali adrenaline ne used during episodes of resuscitation cause

E3

dilatation 3. How is motor function assessed? Each limb is assessed independently for: Spontaneous movement (yes of no) Purposeful movement (yes or no) Strength (normal, weak, none) Posture (normal, decerbrate, decorticate) • • • •

4. How should an infant’s fontanelle be assessed? Palpate the fontanelle and record as normal, sunken, tense, bulging or pulsatile. 5. What vital signs should be recorded? Vital signs are recorded to: Identify those children who may have impaired consciousness as a result of a systemic illness. Detect signs of cerebral ischaemia. (hypertension, bradycardia) Correlate changes in conscious level in children with hypoxia/hypovolaemia. •

•

•

Record:

• • •

Heart rate Blood pressure Respiratory rate and rhythm

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Temperature SpO2 in children with a decreased CGS. 6. What else should be part of the assessment? • •

Record: • • • • •

Occurrence of seizures (time, duration, description) Episodes of vomiting New onset of an inability to swallow secretions (drooling) Complaints of headache or neck pain/stiffness Leak of CSF (clear fluid) from ears or nose

7. W hat action should s hould be taken once the assessment has been performed?  Any deterioration deterioration in in neurological neurological status must: o o o

o

Be reported to the nurse and the doctor in charge of the clinical area. Result in an increased frequency of observations Result in a review of vital signs (including SpO 2) and appropriate treatment if  necessary Ensure that the child is nursed under close observation.

References: Stevens E (2004) Neurological observations: clinical procedure guideline. GOSH Kirkham FJ, Newton CRJ, Whitehouse W (2008) Paediatric Coma Scales Dev Med & Child Neurol 50: 267-174

  Smith J, Martin C (2008) Paediatric neurosurgery for nurses: evidence-based care for children and their families. Rouledge, Abindon Oxon Fairley D, Cosgrove J (2004) Clinical guideline for assessing the Glasgow Coma Scale and pupil response in adult. Leeds general Infirmary   National Institute for Health and Clinical Excellence (2007) Head Injury. Triage, assessment, investigation and early management of head injury in infants, children and adults. NICE, London

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Appendix 1 The paediatric coma scale should be used routinely in accident and emergency departments and on wards and intensive care units for the assessment of any child with: • • • • • • •

trauma (including possible non-accidental injury) iInfection, e.g. meningitis, encephalitis, cerebral malaria epileptic seizures diabetes or other known underlying metabolic abnormality hepatic failure renal failure (including haemolytic–uraemic syndrome) hypertension

In addition, children at risk of the following complications should be assessed frequently: • • • • • • • •

hypoxic–ischaemic injury, e.g. postoperatively (particularly after cardiac surgery) hypotension, especially with shock (e.g. meningococcal) hypertension intracranial hypertension, e.g. with an acute encephalopathy, diabetic coma intra-cranial tumour  after a neuro-imaging procedure requiring sedation or anaesthesia after a neurosurgical procedure, e.g. shunt for hydrocephalus

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