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Regional Guidelines for the Assessment of Level of Consciousness in Children
Date: June 2009 Review Date: June 2011 Lead Author: Dr Mark Darowski
University of Leeds Michelle Milner. Neurosurgical Intensive Care Unit. Children's Services. Leeds Teaching Hospitals NHS Trust Fraser Scott.Emergency Care. Paediatric Critical Care Network Lead Clinician/Consultant Intensivist.doc 2 6/15/2013 . Lecturer in Children Health Nursing. Paediatric Critical Care Network Educator. Mid-Yorkshire Hospitals NHS Trust Jo Smith. Leeds Teaching Hospitals NHS Trust Liz Clancy. Consultant Neurosurgeon.Members of the Advisory Group Mark Darowski (Chair). Calderdale & Huddersfield NHS Foundation Trust Jake Timothy. Children's Network Manager. Matron. Leeds PCT Heather McClelland . Calderdale & Huddersfield Foundation Trust Linda Daniel. Leeds Teaching Hospitals NHS Trust Mark Darowski 152008115. School of Healthcare. Leeds PCT/Leeds Teaching Hospitals NHS Trust Michael Clarke. Consultant Paediatrician. Consultant Paediatric Neurologist. Nurse Consultant . Leeds PCT Sarah Fletcher. Leeds Teaching Hospitals NHS Trust Mick Stone. Paediatric Nurse Practitioner. Charge Nurse.
Mark Darowski 152008115. How often is a child assessed? Initial assessment should be performed on any child meeting the criteria above. observations should revert to half-hourly and follow the original frequency schedule. Abnormal baseline values or changes in values should trigger actions by staff. and theatre recovery areas caring for children.then 2-hourly thereafter. In other situations. These include staff working in children’s wards. The minimum frequency of observations for head injured patients with GCS equal to 15 should be as follows. disorientation or confusion • Has a condition associated with potential neurological impairment (Appendix 1). A&E departments. Trained staff must understand the significance of the assessment in relation to changing levels of consciousness and the importance of accurate documentation and communication of any changes in the child’s condition. as part of their normal duties. Which children require neurological assessment? Any child who • Is suspected of having an altered or changing level of consciousness that is not associated with normal recovery from anaesthesia or sedation.ASSESSMENT OF LEVEL OF CONSCIOUSNESS IN CHILDREN Target audience All nursing and medical staff who.half-hourly for 2 hours. or more frequently. starting after the initial assessment in the emergency department: . PICUs. . • Has behavioral changes. The frequency of assessment must be prescribed and recorded on the chart by the admitting doctor or as described in local guidelines. Who performs the assessment? Staff trained in the performance of the assessment. adult wards and ICUs. 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 agreed frequency may be half hourly. NICE guidelines for the management of patients with head injury suggest that observations should be performed and recorded on a half-hourly basis until GCS equal to 15 has been achieved. Should a patient with GCS equal to 15 deteriorate at any time after the initial 2-hour period. . depending on the child’s condition.then 1-hourly for 4 hours. care for children (0-16 years) with impaired levels of consciousness.doc 3 6/15/2013 . Why perform the assessment? To determine a patient’s level of consciousness and to monitor changes in their condition.
temperature and SpO2 if GCS is abnormal Palpation of fontanelle in infants Recording of other significant events: seizures. Mark Darowski 152008115. Throughout this document we have chosen to use Scale. difficulty in swallowing. How do I perform the assessment? It is usually helpful to include the child’s parent or main carer in the assessment process. • • • • • • • • James’ Modification of the Glasgow Coma Scale* (GCS) Pupillary responses Posture Abnormal eye movement or position Motor power in limbs (weakness) Heart rate. shift change etc) the observations must be performed by the by both nurses together to ensure consistency. if they are present. blood pressure. 1. Verbal response 3. • • • A sleeping child should always be woken for neurological observations It is essential that the child’s normal neurological status and developmental level is established. by involving carers.g.What are the components of neurological assessment? Neurological assessment includes the following components. 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 to the child. ASSESSMENT Before performing a neurological assessment check ABC. In order to this the different elements of the GCS need to be assessed simultaneously (Table 2). Motor response For younger children the responses expected should reflect their stage of development (Table 1). Be aware of the good practice points described in Box 1 below: Box 1. episodes of vomiting. *The terms Scale and Score are both commonly used. The modified Glasgow Coma Scale The level of consciousness is assessed by the patients’ ability to perform 3 activities. At any patient handover (ward transfer. However the assessment must be performed objectively and promptly. 1. in speaking to the child in their own language or when trying to wake them. Eye opening 2. respiratory rate/rhythm. e. CSF leak from ear or nose.doc 4 6/15/2013 . complaints of head/neck pain or visual disturbance. Good practice points. which are scored individually as detailed in table 1.
Pain should be made by pressing hard on the supraorbital notch (beneath medial end of eyebrow) with your thumb.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 V4 V3 V2 V1 T Motor M6 M5 M4 M3 M2 M1 P Notes For children >5y the responses are similar to the adult Glasgow coma scale. ptosis) Orientated Alert. 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. <5yr Spontaneous To voice To pain None Unable to open eyes (swelling. which is tested by pressing hard on the flat finger nail surface with the barrel of a pencil. except for Motor score 4. irritable cry Inappropriate words Cries to pain Incomprehensible sounds Moans to pain No response to pain Child is intubated Obeys commands Normal spontaneous movements Withdraws to touch (<9mo) Localizes to supraorbital pain (>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 Mark Darowski 152008115. Score as usual in the presence of possibly sedating drugs. words or sentences – normal for age Confused Less than usual ability. coos. If in doubt repeat after 5 minutes and ask for a second opinion.doc 5 6/15/2013 . Score the best response if unclear or asymmetrical. Plot scores over time on a suitable chart. babbles. then pinch the earlobe as an alternative stimulus.
Step 2 If the child’s eyes are closed.Step 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. Supraorbital pressure is the stimulus of choice (Box 2). pinch the ear lobe to provide an alternative stimulus. talk to them and observe whether their eyes open in response to a verbal stimulus (E3). Step 3 3. press firmly on the supra-orbital notch (beneath the medial end of the eyebrow) with your thumb. If you are not confident about supra-orbital pressure. Box 2. If a child appears to understand what is said to them. This feels different to the pressing feeling and stops as soon as you stop pressing. try the technique on yourself first: press hard enough to elicit a very focal sharp pain. If there are facial fractures or severe swelling involving the supraorbital ridge. Applying the stimulus • • • • To apply supraorbital pressure.g. Observe the child’s verbal and motor response e.g. Mark Darowski 152008115. Explain to the carer that you are going to press on the child’s forehead to see if they will respond to pain. squeeze the carer’s finger or squeeze his eyes shut (M6). ask the child to obey a simple command. In infants and children with developmental delay. If there is no attempt to verbalise or move when the assessor talks or gently touches the child. proceed to Step 2. If this is the case. If the child does not have any spontaneous speech or eye opening. observe whether they appear to recognize the carer and understand what is said. even if they are not speaking. or nailbed pressure. 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 the child’s usual ability (V4). elicit a verbal and motor responses as for Step 1. watch for normal spontaneous movement (M6). proceed to Step 3.doc 6 6/15/2013 .1 A painful stimulus must be applied to complete the assessment. e. If the child opens their eyes. Apply nailbed pressure tested by pressing hard on the flat finger nail surface with the barrel of a pencil.
particularly if the pupil size and response to light is also asymmetrical. with plantar flexion of the feet. The eyes open (E3) 2. In this posture. do not use a limb with an obvious injury.doc 7 6/15/2013 . Flexion is assessed in the arms. Moves their arms: – Above the clavicle (with supraorbital pressure). Fig 2 Decerebrate posture results from damage to the upper brain stem. The legs are stiffly extended and internally rotated. with the wrists and fingers flexed on the chest. which could indicate impending uncal herniation. M5) – Below the clavicle but flexing at the elbow (flexion to pain. In this posture. or to remove the painful stimulus if another stimulus is used (localization to pain.Observe and document the child’s response: 1. If there is asymmetry when assessing record the best response. Mark Darowski 152008115. press more firmly (as hard as you can) and observe whether there is movement of any body part. the arms are adducted and flexed. An absence of body movement in a child whose face moves may suggest a spinal cord injury. or moans or makes incomprehensible sounds(V2) 3. with the wrists pronated and the fingers flexed. M4). with plantar flexion of the feet. Cries or uses inappropriate words(V3). If the child does not move following the initial application of a painful stimulus. Record and report asymmetrical movement. M3) Fig 1 – Below the clavicle without flexion but with rotation at the shoulder (extension. If the child flexes but does not localize apply nail bed and pressure observe whether or not the child moves the finger away (withdrawal to pain. the arms and adducted and extended. including the face (grimace). The legs are stiffly extended. M2) Fig 2 – No movement (M1) Fig 1 Decorticate Posture results from damage to one or both corticospinal tracts.
even when verbal and motor scores are high. Paralysed children If the child is paralysed (muscle relaxants or spinal cord injury) record P for motor response. A total score of 15 (E4. 3. If there is asymmetry of the motor or eye opening response. V4. an aggregate score can mask important changes. verbal response. A summated score can provide a quick guide to a child’s level of consciousness. The eye opening. Observe the eye opening and verbal responses to pain at the same time. A score of 8 represents severely impaired consciousness and may require airway support. not just a simple withdrawal (M4). Intubated children For intubated patients. score eye opening and motor responses as above and write down T (for ‘tube’) for the verbal score. V5. verbal and motor responses are always assessed and communicated separately. Many paediatric intensive care units have adopted the grimace scale in place of the verbal scale.g. Step 4 Document the date and time at which the observations were performed. Although there is good inter-observer agreement it has not yet been assessed as a tool for the prediction of outcome. apply an earlobe pinch. e.3 If you cannot feel one or other supra-orbital notch. A decrease of 1 point in the motor score or an overall deterioration of two points is considered significant.V5. or M6. orientated patient. M5. A score of 3 indicates a deep coma.g.M6) represents an alert. When assessing infants the eye opening score is often E1 (none).2 When assessing an infant touch and stroke the child on the hand and forearm and note any withdrawal to touch (M5). Mark Darowski 152008115. because of traumatic facial swelling. Write down the response observed for eye opening. 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 to remove the pain.doc 8 6/15/2013 . and motor response. e.3. write down the better side.
squeeze the carer’s finger or squeeze his eyes shut.g.Children’s Glasgow Coma Scale: A step-by step guide Step 1 Eyes Eyes open? Yes E4 Box 1. Ask carer to elicit a verbal and motor esponse appropriate to the child’s age e.Normal Verbal Responses. Infants – first assess withdrawal to touch Eyes Eyes open E2 Eyes do not Cries V3 Verbal Moans V2 No verbal response V1 Localises to pain M5 Flexes to pain Apply nail bed pressure Withdraws to pain? Yes M4 No M3 Motor Extends to pain M2 No response to pain Increase supraorbital pressure Grimace? No M1 Yes open E1 Step 4 Record Response E4 E3 E2 E1 V5 V4 V3 V2 V1 M6 M5 M4 M3 M2 M1 ? Spinal Injury Mark Darowski 152008115.M6 No Apply supra-orbital pressure. If child’s eyes are open (E4) ask the carer to talk to the child in a familiar language. Babbling if < 9 months Any words from 12 months Any sentences from 2 years Orientation in place and time from 5 years Waving bye for a child 9-12 months Putting hairbrush to head for child aged 12 – 15 months Pointing to parts of the body for child aged 15 – 24 months No Do eyes open to speech? Step 2 Verbal Yes E3 No Elicit verbal response Normal response V5 Impaired response V4 (see Box 1) No response Elicit motor response by asking the child to obey simple commands e.g. Obeys Commands? Step 3 Motor Yes .doc 9 6/15/2013 .
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. sluggish (S) or closed (C) • Equality . Eye drops given before ophthalmologic examination and adrenaline used during episodes of resuscitation cause dilatation 3. Deviation may be normal (squint -ask the family). none) • Posture (normal. both pupils should dilate simultaneously. weak. How should an infant’s fontanelle be assessed? Palpate the fontanelle and record as normal. When light is withdrawn. Both eyes should be central looking forward. no response/fixed (F). bulging or pulsatile. tense.doc 10 6/15/2013 .of size and of response Pupillary responses may be affected by medication. Opiates cause constriction. decerbrate. New deviation may be the sign of significant disease.recorded as brisk (record as B). Record: • Heart rate • Blood pressure • Respiratory rate and rhythm Mark Darowski 152008115. Light in one eye should cause simultaneous constriction of both pupils. moderate or dilated • Reactivity to light . (hypertension. How is motor function assessed? Each limb is assessed independently for: • Spontaneous movement (yes of no) • Purposeful movement (yes or no) • Strength (normal. sunken. Observe pupils without stimulation for size and equality Shine light into each eye in turn.2. Allow 5 seconds before testing the opposite eye to allow for recovery of the consensual light reflex. How do I measure pupillary responses? Responses should be elicited using a bright pen torch (not an opthalmoscope. E3 The responses of each pupil are described in terms of • Size – recorded as pinpoint. small. • • • Open both eyes. bradycardia) • Correlate changes in conscious level in children with hypoxia/hypovolaemia. otoscope or laryngoscope). if possible. in low ambient lighting. decorticate) 4. 5. • Detect signs of cerebral ischaemia.
Martin C (2008) Paediatric neurosurgery for nurses: evidence-based care for children and their families. Abindon Oxon Fairley D. assessment. investigation and early management of head injury in infants. o Result in an increased frequency of observations o Result in a review of vital signs (including SpO2) and appropriate treatment if necessary o Ensure that the child is nursed under close observation. 6. children and adults. Whitehouse W (2008) Paediatric Coma Scales Dev Med & Child Neurol 50: 267-174 Smith J. Newton CRJ.• Temperature • SpO2 in children with a decreased CGS. London Mark Darowski 152008115. NICE. References: Stevens E (2004) Neurological observations: clinical procedure guideline. 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.doc 11 6/15/2013 . Triage. What action should be taken once the assessment has been performed? Any deterioration in neurological status must: o Be reported to the nurse and the doctor in charge of the clinical area. GOSH Kirkham FJ. What else should be part of the assessment? Record: • Occurrence of seizures (time. Leeds general Infirmary National Institute for Health and Clinical Excellence (2007) Head Injury. Cosgrove J (2004) Clinical guideline for assessing the Glasgow Coma Scale and pupil response in adult. duration. Rouledge.
meningitis. diabetic coma intra-cranial tumour after a neuro-imaging procedure requiring sedation or anaesthesia after a neurosurgical procedure.g. e.doc 12 6/15/2013 . encephalitis.g. meningococcal) hypertension intracranial hypertension.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.g.g. postoperatively (particularly after cardiac surgery) hypotension. with an acute encephalopathy.g. cerebral malaria epileptic seizures diabetes or other known underlying metabolic abnormality hepatic failure renal failure (including haemolytic–uraemic syndrome) hypertension In addition. e. e. e. children at risk of the following complications should be assessed frequently: • • • • • • • • hypoxic–ischaemic injury. especially with shock (e. shunt for hydrocephalus Mark Darowski 152008115.