Table 4

Emergency management of the unconscious patient

Establish airway and give high flow oxygen by mask
Measure blood pressure and resuscitate with salt containing fluids/inotropes if low; do not reduce immediately if high
Perform Dextrostix testing and simultaneous true blood sugar and give dextrose if low
Assess level of consciousness using the modified Glasgow coma scale (table 1)
Assess brain stem function (table 2) and decide whether the patient has evidence of central or uncal herniation (table 3)
Lift the eyelids and look for tonic deviation of the eyes or nystagmus
Examine the fundi for papilloedema (rarely seen in acute encephalopathy; absence does not exclude intracranial hypertension), retinal haemorrhages, and macular star suggestive of hypertension
If modified Glasgow coma score is less than 12 or there is evidence of herniation, intubate and ventilate
If modified Glasgow coma score is between 12 and 14, or intubation is not possible immediately and there is evidence of progressive uncal or central herniation (table 3), give mannitol 0.25 g/kg
If there is tonic deviation of the eyes or nystagmus, assume subtle status epilepticus and give a benzodiazepine and/or phenytoin
If the child is febrile and is either under the age of 12 months or is older than 12 months and has a Glasgow coma score greater than 12, undertake a lumbar puncture (table 5) after checking that the child is not in subtle status. The CSF pressure should be measured with a transducer or a manometer. A dose of mannitol 0.25 g/kg should be given if the pressure is greater than 15 cm H2O or if there is evidence of deterioration in the modified Glasgow coma score or the brain stem signs after the lumbar puncture. If the CSF is cloudy, dexamethasone may be given before starting a third generation cephalosporin
If the child is afebrile or febrile with a deteriorating level of consciousness, do not perform lumbar puncture, but start a third generation cephalosporin and aciclovir and ring the nearest paediatric intensive care unit with access to a neurosurgical unit to request transfer by their transport team for CT scan and further management