Decreased Conscious Level in a Child

Authors: Sarah Jones, Maya K Naravi / Editor: Nicola McDonald / Reviewer: Thomas Mac Mahon, Nadarajah Prasanna, Sandi Angus / Codes: / Published: 17/12/2020 / Reviewed: 14/03/2024

The child with decreased consciousness is a common problem with many possible diagnoses and potentially high mortality and morbidity. It is therefore important for the emergency physician to rapidly recognise children with decreased consciousness and initiate appropriate investigations and correct emergency treatment.

After completing this session you will be able to:

  • Evaluate which conscious level scores can be used in a child aged 0-18 years to define a decreased conscious level
  • Identify which conditions present as a decreased consciousness and which clinical features will facilitate the diagnosis
  • Select appropriate core set of investigations depending on the presentation
  • Interpret initial observations and investigations
  • Choose appropriate management/treatment steps to initiate life-saving treatment without delay


  1. Management of children and young people with an acute decrease in conscious level | A nationally developed evidence-based Guideline for practitioners | RCPCH Revised in 2019.
  2. Tintinalli JE.  Emergency Medicine a comprehensive study guide. American College of Emergency Physicians 6th ed 2004 831-835.
  3. Crossman AR, Neary D. Neuroanatomy: an illustrated colour text. Elsevier, 2018; 6th Edition.
  4. Chan KC, Tse NKC, et al. Introducing the Guideline on the Management of a Child with a Decreased Conscious Level: A Nationally Developed Evidence-based Guideline for Hospital Practitioners (The Paediatric Accident and Emergency Research Group, The University of Nottingham). HK J Paediatr (new series) 2013;18:105-116.
  5. Smith S. Advanced paediatric life support: A practical approach to emergencies. 7th ed. Advanced Life Support Group (ALSG), editor. Hoboken, NJ: Wiley-Blackwell; 2023.
  6. Kirkham FJ, Newton CR, Whitehouse W. Paediatric coma scales. Developmental Medicine & Child Neurology. 2008 Apr;50(4):267-74.
  7. American College of Surgeons. ATLS Student Course Manual, 10th edition. 2018.
  8. Hon KL, Ho JK, Hung EC, Cheung KL, Ng PC. Poisoning necessitating pediatric ICU admissions: size of pupils does matter. J Natl Med Assoc. 2008 Aug;100(8):952-6.
  9. Binchy JM, Molyneux EM, Manning J. Accidental ingestion of methadone by children in Merseyside. BMJ. 1994 May 21;308(6940):1335-6.
  10.  Tiras S, Haas V, Chevret L, et al. Nonketotic hyperglycemic coma in toddlers after unintentional methadone ingestion. Ann Emerg Med. 2006 Oct;48(4):448-51.
  11. McKenny-Fick NM, Ferrie CD, Livingston JH, Taylor JC, Allen JE. Prolonged recovery of consciousness in children following symptomatic epileptic seizures. Seizure. 2009 Apr;18(3):180-3.
  12. Okumura A, Uemura N, et al. Unconsciousness and delirious behavior in children with febrile seizures. Pediatr Neurol. 2004 May;30(5):316-9.
  13. National Institute for Health and Care Excellence (NICE). Fever in under 5s: assessment and initial management. [NG143] 2019. Last updated: 26 November 2021
  14. National Institute for Health and Care Excellence (NICE). Head injury: assessment and early management. [NG232] 2023.
  15. Jenny C, Hymel Kp, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma.JAMA. 1999;281:621-6
  16. National Institute for Health and Care Excellence (NICE). Diabetes (type 1 and type 2) in children and young people: diagnosis and management. [NG18] 2015. Last updated: 11 May 2023.
  17. Brouwer MC, McIntyre P, Prasad K, van de Beek D. Corticosteroids for acute bacterial meningitis. Cochrane Database of Systematic Reviews 2015, Issue 9. Art. No.: CD004405.
  18. Abbas BB, Abdolvahab A, et al. Clinical signs as a guide for performing HSV PCR in correct diagnosis of herpes simplex virus encephalitis. Neurology India 2003;51:341-344
  19. Frazier JL, Ahn ES, Jallo GI. Management of brain abscesses in children. Neurosurgical focus 2008;24:E8
  20. Gayatri NA, Whitehouse WP. Pilot survey of Hashimotos encephalopathy in children. Dev Med Child Neurol. 2005 Aug;47(8):556-8.
  21.  Desachy A, Vuagnat AC, et al. Accuracy of bedside glucometry in critically ill patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc. 2008 Apr;83(4):400-5.
  22. Anderson CE, Loomis GA. Recognition and prevention of inhalant abuse. Am Fam Physician 2003;68:869-874
  23. Mrvos R, Swanson-Biearman B, Krenzelok EP. Backyard mushroom ingestions: no gastrointestinal decontamination–no effect. J Emerg Med. 2007 Nov;33(4):381-3.
  24. National Institute for Health and Care Excellence (NICE). Diarrhoea and vomiting caused by gastroenteritis in under 5s: diagnosis and management. [CG84] 2009.
  25. Blount JP, Oakes JO, Tubbs S, C PA, Humphreys RP. History of surgery for cerebrovascular disease in children. Part 1. Intracranial arterial aneurysms. Neurosurg. Focus. 2006: E10
  26.  Hobbs C, Childs AM, Wynne J, Livingston J, Seal A. Subdural haematoma and effusion in infancy:an epidemiological study. Arch Child Dis 2005;90:952-955.
  27. Younis RT, Anand VK , Davidson B. The role of Computerised tomography and magnetic resonance imaging in patients with sinusitis complications. Laryngoscope 2002;112:224-229.
  28. Bacon M, Appleton R, Bangalore H, et al. Review of the new APLS guideline (2022): Management of the convulsing child. Arch Dis Child Educ Pract Ed. 2023 Feb;108(1):43-48.

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