Paediatric ECAT protocol

Altered conscious state

P4.1 Published: December 2023 Printed on 19 May 2024

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Any person, 4 weeks to 15 years, presenting with an altered level of consciousness.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

If known or suspected poisoning, switch to poisoning (suspected or confirmed) protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

Presenting complaint
Onset of symptoms
Events leading to unconscious event, including potential envenomation, exposure or ingestion of toxin
History of recent illness
Pain assessment
Pre-hospital treatment
Past admissions
Medical and surgical history, including a history of any similar episodes, seizures, diabetes, head injury or trauma
Current medications
Drug or alcohol use
Known allergies
Immunisation status
Current weight

Signs and symptoms

Non-rousable or rousing to voice or pain only
Signs of injury
Signs of intoxication and/or drug use
Fever
Drowsy or lethargic
Headache

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

Suspected exposure and/or ingestion of toxin

Clinical

Airway compromise
Hypoventilation
Snoring
Odorous breath, e.g. ketotic or alcohol
Head injury
Unequal pupils
Weakness or paralysis
Signs of raised increased intracranial pressure (ICP)
Non-blanching rash

Remember child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

Assessment	Intervention
General appearance/first impressions No cervical spine injury	Position supine, or in recovery position, depending on level of consciousness Elevate head to 30°
Suspected cervical spine injury	Stabilise the C-spine with in-line immobilisation or foam collar (appendix)

Assessment

Intervention

General appearance/first impressions

No cervical spine injury

Position supine, or in recovery position, depending on level of consciousness

Elevate head to 30°

Suspected cervical spine injury

Stabilise the C-spine with in-line immobilisation or foam collar (appendix)

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Auscultate chest (breath sounds) Oxygen saturation (SpO₂)	Assist ventilation as clinically indicated If there is an absence of effective breathing or no signs of life commence CPR, switch to cardiorespiratory arrest protocol Apply oxygen to maintain SpO₂ over 93% If hypoxic or signs of hypoventilation, consider opiate overdose
Suspected opiate overdose, e.g. hypoventilation and difficult to rouse	Escalate as per local CERS protocol and give naloxone 10 microg/kg IV/IM, maximum dose 400 microg. Repeat dose if required, every 2 minutes, until the patient is more awake and breathing adequately. Maximum total dose 2 mg If no response, consider non-opiate cause or fentanyl analogue

Assessment

Intervention

Respiratory rate and work of breathing

Auscultate chest (breath sounds)

Oxygen saturation (SpO₂)

Assist ventilation as clinically indicated

If there is an absence of effective breathing or no signs of life commence CPR, switch to cardiorespiratory arrest protocol

Apply oxygen to maintain SpO₂ over 93%

If hypoxic or signs of hypoventilation, consider opiate overdose

Suspected opiate overdose, e.g. hypoventilation and difficult to rouse

Escalate as per local CERS protocol

and give naloxone 10 microg/kg IV/IM, maximum dose 400 microg. Repeat dose if required, every 2 minutes, until the patient is more awake and breathing adequately. Maximum total dose 2 mg

If no response, consider non-opiate cause or fentanyl analogue

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation If bradycardic or absent pulse commence CPR, switch to cardiorespiratory arrest protocol If hypertensive, consider raised intracranial pressure If Cushing’s triad, i.e. hypertensive, bradycardic and irregular breathing pattern, escalate as per local CERS protocol Attach continuous cardiac monitor Attach defibrillator and follow local guidelines
IVC and/or pathology	Insert IV cannula, if trained If unable to obtain IV access, consider intraosseous, if trained See pathology section
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension	If signs of shock present, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL If further fluid resuscitation is required, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL

Assessment

Intervention

Perfusion (capillary refill, skin warmth and colour)

Heart rate

Blood pressure

Cardiac rhythm

Assess circulation

If bradycardic or absent pulse commence CPR, switch to cardiorespiratory arrest protocol

If hypertensive, consider raised intracranial pressure

If Cushing’s triad, i.e. hypertensive, bradycardic and irregular breathing pattern, escalate as per local CERS protocol

Attach continuous cardiac monitor

Attach defibrillator and follow local guidelines

IVC and/or pathology

Insert IV cannula, if trained

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL

If further fluid resuscitation is required, give sodium chloride 0.9% at 10 mL/kg IV/intraosseous bolus, maximum dose 1000 mL

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment, as clinically indicated
Seizure activity	Measure BGL. See glucose section for management Note: give a maximum of 2 doses of benzodiazepines in any seizure episode, inclusive of out of hospital treatment Select: IV access No IV access IV access Give midazolam 0.15 mg/kg IV, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg No IV access Give: midazolam 0.15 mg/kg IM once only. Maximum dose 10 mg or midazolam 0.3 mg/kg intranasal/buccal, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg Escalate as per local CERS protocol for second-line seizure management

Assessment

Intervention

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment, as clinically indicated

Seizure activity

Measure BGL. See glucose section for management

Note: give a maximum of 2 doses of benzodiazepines in any seizure episode, inclusive of out of hospital treatment

Select:

IV access
No IV access

IV access

Give midazolam 0.15 mg/kg IV, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg

No IV access

Give:

midazolam 0.15 mg/kg IM once only. Maximum dose 10 mg
or midazolam 0.3 mg/kg intranasal/buccal, maximum single dose 10 mg. Repeat once after 5 minutes if seizure continues. Maximum total dose 20 mg

Escalate as per local CERS protocol for second-line seizure management

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses

Glucose

Assessment	Intervention
BGL	Measure BGL. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give 40% glucose gel buccal reassess BGL in 15–30 minutes until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access give 10% glucose, 2 mL/kg by slow IV injection, once only if IV access delayed, give: Up to 25 kg: glucagon 0.5 mg IM, once only 25 kg and over: glucagon 1 mg IM, once only reassess BGL in 15 minutes Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated If BGL over 10 mmol/L: check blood ketones escalate as per local CERS protocol

Assessment

Intervention

BGL

Measure BGL. See medication table for 40% glucose gel dosing

If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):

give 40% glucose gel buccal
reassess BGL in 15–30 minutes until BGL over 3 mmol/L

If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:

give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access
give 10% glucose, 2 mL/kg by slow IV injection, once only
if IV access delayed, give:
- Up to 25 kg: glucagon 0.5 mg IM, once only
- 25 kg and over: glucagon 1 mg IM, once only
reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

If BGL over 10 mmol/L:

check blood ketones
escalate as per local CERS protocol

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete a secondary survey.

Complete a neurological focused assessment.

Precautions and notes

Consider cause and alternative ECAT protocol if required.
Consider the possibility of non-accidental injury.
The half-life of naloxone is shorter than opiates. For patients suspected of opioid drug overdose, repeated doses of naloxone may be required.
If IV access is unavailable, both doses of naloxone may be given IM, but the IM route is slower to take effect.

Interventions and diagnostics

Specific treatment

Specific treatment will be determined by the underlying cause.

Radiology

Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.

Pathology

FBC, UEC, LFT, glucose, Ca/Mg/PO4, VBG with lactate, blood cultures
Urinalysis:
- Patient who can void in the toilet: mid-stream urine
- Patient who is not toilet trained: clean catch or catheter urine
- If positive for nitrites and/or leucocytes, send for MC&S. Keep sample refrigerated if transport is delayed.
Bleeding or history of head trauma: coags, group and hold
Post-menarche: urine βHCG

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug	Dose	Route	Frequency
Glucagon	Up to 25 kg: 0.5 mg 25 kg and over: 1 mg	IM	Once only
Glucose 10%	2 mL/kg	Slow IV injection	Once only
Glucose 40% gel (0.4 g/mL)	4 weeks–1 year: 200 mg/kg (=0.5 mL/kg) 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g	Buccal	Repeat after 15 minutes if required
Midazolam	0.15 mg/kg Maximum single dose 10 mg Maximum total dose 20 mg	IV	Repeat once if required after 5 minutes
	OR
	0.15 mg/kg Maximum dose 10 mg	IM	Once only
	OR
	0.3 mg/kg Maximum single dose 10 mg Maximum total dose 20 mg	Buccal/intranasal	Repeat once if required after 5 minutes
Naloxone	10 microg/kg Maximum single dose 400 microg Maximum total dose 2 mg	IV/IM	Repeat dose if required every 2 minutes, until the patient is more awake and breathing adequately
Oxygen	0.25–15 L/min, device dependent	Inhalation	Continuous
Sodium chloride 0.9%	10 mL/kg Maximum dose 1000 mL	IV/intraosseous	Bolus Repeat once if required

Medications with contraindications or requiring dose adjustment are marked:

^H for patients with known hepatic impairment
^R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

Show

Song JL, Wang VJ. Altered Level Of Consciousness: Evidence-Based Management In The Emergency Department. Pediatr Emerg Med Pract. 2017 Jan;14(1):1-28.
NSW Health. AMH Children's Dosing Companion. Australia: Australian Government, NSW; 2023 [cited 23 Feb 2023]. Available from: https://childrens.amh.net.au/auth
Australian Resuscitation Council. ANZCOR Guideline 12.2 – Paediatric Advanced Life Support (PALS). Australia: Australian Resuscitation Council; 2021 [cited 28 Feb 2023]. Available from: https://resus.org.au/download/anzcor-guideline-12-2-paediatric-advanced-life-support-pals-november-2021-1-7-mib/?wpdmdl=13782&masterkey
NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2023 [cited 28 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Altered conscious state. Melbourne: Victoria Health; 2022 [cited 28 Feb 2023]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Altered_conscious_state/
MIMS Australia. Clinical Resources. MIMS Online. Australia: MIMS Australia; 2023 [cited 28 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
Michelson D, Thompson L, Williams EA. Evaluation of stupor and coma in children. The Netherlands: Wolters Kluwer; 2018 [cited 28 Feb 2023]. Available from: https://www.uptodate.com.acs.hcn.com.au/contents/evaluation-of-stupor-and-coma-in-children?search=unconscious%20child&source=search_result&selectedTitle=1~139&usage_type=default&display_rank=1#H25
Hunter L, Illman J, Nieto-Hernandez R, et al. Management of children and young people with an acute decrease in conscious level (RCPCH guideline update 2015). United Kingdom: The Royal College of Paediatrics and Child Health and The University of Nottingham; 2019 [cited 28 Feb 2023]. Available from: https://www.rcpch.ac.uk/sites/default/files/2019-04/decon_guideline_revised_2019_08.04.19.pdf
Mastrangelo M, Baglioni V. Management of Neurological Emergencies in Children: An Updated Overview. Neuropediatrics. 2021 Aug;52(4):242-51. DOI: 10.1055/s-0041-1730936
The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
Agency for Clinical Innovation. Rural Paediatric Emergency Clinical Guidelines - Third Edition. Sydney: NSW Health; 2021 [cited 28 Feb 2023]. Available from: https://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2021_011

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Evidence informed	Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.
Collaboration	This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.
Currency	Due for review: Jan 2026. Based on a regular review cycle.
Feedback	Email ACI-ECIs@health.nsw.gov.au

ECAT home page Glossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/paediatric/altered-conscious-state

Altered conscious state

On this page

History prompts, signs and symptoms

History prompts

Signs and symptoms

Red flags

Historical

Clinical

Clinical assessment and specified intervention (A to G)

Position

Airway

Breathing

Circulation

Disability

IV access

No IV access

Exposure

Fluids

Glucose

Focused assessment

Precautions and notes

Interventions and diagnostics

Specific treatment

Radiology

Pathology

Medications

References