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The management of children and young people with an acute decrease in conscious level

This guideline provides healthcare professionals with guidance on identifying and managing decreased conscious level in children. It aims to improve assessment, reduce misdiagnosis, and standardize treatment.

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The management of children and young people with an acute decrease in conscious level

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  1. The management of children and young people with an acute decrease in conscious level Funded by: Endorsed by: Supported by: PATRON HRH The Princess Royal

  2. Guideline aims and objectives This guideline aims to provide healthcare professionals with guidance on the identification and management of decreased conscious level in children The aim of the guideline is to help: • Improve and standardise assessment, investigation and treatment of the child presenting with a decreased conscious level. • Reduce the risk of misdiagnosis and delay of lifesaving treatment.

  3. Background • Original guideline based on The Management of a Child with a Decreased Conscious Level (2005 Paediatric Emergency Research Group guideline) • Audit conducted in 2010 – 11, published in 2012 • A national evidence-based guideline for practitioners • 2015 update now available

  4. Definitions The term ‘child’ is used throughout for an infant, child or young person A decreased conscious level is defined as: • being responsive only to voice, or pain, or; • being unresponsive on the AVPU scale, or; • a Glasgow Coma Score or modified Glasgow Coma Score of 14 or less

  5. Introduction This guideline is relevant for all children and young people from 4 weeks to 18 years, presenting acutely with a decreased level of consciousness. A child presenting with a Decreased Conscious Level is a significant neurological emergency Requires a rapid & and systematic approach to management at first presentation This presentation indicates a primary insult to the brain which if untreated may progress to secondary damage Reference is made to relevant National Guidelines when indicated, without repeating all of the information

  6. Methodology Guideline Development Group (GDG) established: • Methodology advisory group • Literature review working group • Delphi working group

  7. What this guideline covers • Assessment of: • airway, airway protection, breathing & oxygen requirements • capillary glucose • Observations to monitor and help manage children • Managing the causes of decreased conscious level • Good practice points • Special circumstances

  8. What this guideline does notcover • Neonates ≤ 28 days • Pre-term infant survivors on neonatal intensive care units • Children with a previously diagnosed condition • Children who score ≤ 14 on the Glasgow Coma Scale or Modified Glasgow Coma Scale • Conditions addressed by other guidelines : • Non-ketotichyperglycaemia • Peri-arrest management

  9. 95 recommendations, across 12 categories A comprehensive clinical history should be taken irrespective of differential diagnosis Clinical history documentation should include: information on the presence of a feature and its absence reasons if unable to obtain an adequate history If regular evaluation of conscious level is required, GCS measurements should be commenced in addition to / instead of AVPU Key recommendations (for health professionals)

  10. Using the guideline The recommendations are laid out in the following sections: • Recommendation(s) • Quality of evidence • Review question(s) • Evidence summary • Delphi statement(s) • Evidence interpretation

  11. Using the guideline (continued) • Due to varying level of evidence, some recommendations can be made with more certainty than others. The strength of evidence behind the recommendations has been reflected in their wording (for further information on this approach refer to the NICE Guidelines Manual): • Weak evidence: ‘Consider’ has been used to indicate where a recommendation has been based on a Delphi consensus or weak evidence. • Strong evidence: Recommendations are worded more strongly using simply a verb or the word ‘should’ where there is stronger evidence supporting the recommendation. • This method of using wording to convey the strength of the evidence underlying a recommendation has been followed throughout the guideline with two exceptions, both of which can be considered best practice. These are: • where a recommendation cross-refers to other related guidance • where the recommendation relates to issues about child safety 

  12. Developing the clinical questions broken down into formulated into Review questions Scope Key issues

  13. Developing the clinical questions Scope: provide an update of the 2005 guideline and include alcohol intoxication Clinical questions: previous (2005) clinical questions were reviewed and amendments were made, or questions excluded Alcohol intoxication: review questions were formed, based on the scope, and a protocol prepared for each question Review questions: considered population, intervention, comparison and outcome for reviews of management of alcohol intoxication, and guided the literature searches, critical appraisal and synthesis of evidence, and facilitated recommendation development

  14. Identifying the evidence Review questions • formed the starting point for systematic reviews • 71 review questions searched • searches run on core databases • no grey literature or hand searching

  15. Identifying the evidence (cont.) Search process • searched literature published from Jan 2004 - Sept 2014 (except alcohol intoxication questions, Jan 1990 - September 2014) • re-execution of searches within 8 weeks of the start of the stakeholder consultation • searches completed by 1 September 2014

  16. Reviewing & synthesising the evidence Identification of evidence • relevant evidence identified by the project manager and literature review group Post-initial review • after initial review, a proportion of papers were reviewed by a 2nd reviewer Critical appraisal • papers were appraised using checklists • key information extracted (e.g. population, methods & results) • the type of clinical question determined the highest level of evidence that may be sought

  17. Developing & grading recommendations Grade of recommendations • Represents recommendations based on systematic reviews (with homogeneity) of the most robust evidence possible depending upon the type of underlying clinical question A • Represents recommendations based on consensus, expert opinion, case series or studies with “troublingly inconsistent or inconclusive” findings D

  18. Delphi process Delphi panel • consisted of 67 healthcare specialists Formulation of statements • statements were formulated using a Likert Scale, where the GDG felt that the original guideline needed updating and there was no substantial evidence found How was it conducted? • 2 rounds in the questionnaire, rate of return: • round 1: part 1 (50.4%), part 2 (47.5%) • round 2: 69.8% • round 2 (sepsis): 17.4% • A 3rd round was conducted for specific unanswered metabolic and sepsis questions (31.4%)

  19. Participation Parents, carers and young people • participated in the Delphi consensus survey • deemed important to gather opinions on the good practice recommendations Stakeholders • sought stakeholder involvement at all stages of development • due to the breadth of the scope, input required from a variety of specialities Guideline Development Group (GDG) • representation from stakeholders, where stakeholders commented on the draft scope and draft guideline / recommendations

  20. Erratum Please check that you’ve downloaded the most recent version of the published Guidance, as an Erratum was published in August 2016 Available from: http://www.rcpch.ac.uk/decon2015

  21. Resources Full guideline and appendices Summary of recommendations Algorithm poster for the management of care http://www.rcpch.ac.uk/decon2015 Training slides

  22. Acknowledgements RCPCH Research & Policy Division Project manager – Lindsey Hunter Project Coordinator – Jenni Illman Project consultant – Roz Ullman Guideline Development Group – Stephanie Smith, Consultant Emergency Paediatrician, Nottingham Children’s Hospital (Chair) Guideline Development Group Reyes Foundation Delphi Panellists Review Group Stakeholders Nottingham University

  23. Thank youAny questions? The report can be obtained from the RCPCH Research & Policy stand, RCPCH website or the Clinical Standards Team http://www.rcpch.ac.uk/decon2015 clinical.standards@rcpch.ac.uk

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