From the Guidelines
The next step in management for this 11-year-old girl with decreased level of consciousness should be a head CT (option c). This patient presents with a concerning neurological picture - she cannot be roused, doesn't open her eyes, and only moans to painful stimuli, indicating a significantly altered mental status. The preceding vomiting for two days without fever or abdominal pain could suggest increased intracranial pressure, as indicated by early signs of increased ICP such as decreased level of consciousness and potential changes in blood pressure or heart rate 1. Given her decreased level of consciousness, it's critical to rule out life-threatening intracranial pathologies such as hemorrhage, mass effect, hydrocephalus, or cerebral edema before proceeding with other interventions.
While bloodwork is important, the neurological presentation demands immediate brain imaging, as emphasized by the need for urgent assessment and access to neuroimaging for patients with falling level of consciousness 1. A lumbar puncture would be contraindicated before ruling out increased intracranial pressure with imaging, as it could precipitate herniation. Reassurance and monitoring alone would be inadequate given the severity of her presentation. After the CT, further management would depend on findings, but would likely include bloodwork, possible lumbar puncture if safe, and appropriate interventions based on the underlying cause. The priority is to ensure airway protection, ventilatory support, and management of raised intracranial pressure, as outlined in the guidelines for managing patients with suspected acute encephalitis 1.
Key considerations in her management include:
- Immediate brain imaging to rule out life-threatening intracranial pathologies
- Urgent assessment by pediatric intensive care unit staff for airway protection and ventilatory support
- Management of raised intracranial pressure and optimization of cerebral perfusion pressure
- Correction of electrolyte imbalances and access to pediatric neurological specialist opinion 1.
From the Research
Initial Assessment and Management
The patient presents with decreased level of consciousness (LoC) and a history of vomiting for 2 days. The first step in management would be to assess the patient's airway, breathing, and circulation (ABCs) and ensure that they are stable.
Diagnostic Approach
Given the patient's presentation, a thorough diagnostic approach is necessary to determine the underlying cause of the decreased LoC. This may include:
- Bloodwork: CBC, lytes, Cr to rule out any electrolyte imbalances or infections 2
- Imaging studies: Head CT to rule out any intracranial abnormalities such as subarachnoid hemorrhage or mass lesions 3, 4
- Lumbar puncture and CSF analysis: to rule out central nervous system infections such as meningitis or encephalitis 5, 6
Next Step in Management
Based on the patient's presentation, the next step in management would be to perform a Head CT to rule out any intracranial abnormalities. This is because the patient's decreased LoC and history of vomiting could be indicative of a subarachnoid hemorrhage or other intracranial abnormality. If the Head CT is non-diagnostic, a lumbar puncture and CSF analysis may be necessary to rule out central nervous system infections 5, 3, 4.
Considerations
It is essential to note that performing a lumbar puncture without prior imaging may be risky if there is a possibility of increased intracranial pressure. Therefore, a Head CT should be performed first to rule out any contraindications to lumbar puncture 4. Additionally, the use of cranial imaging prior to lumbar puncture has been associated with delayed treatments and poor outcomes in patients with suspected central nervous system infections 4. However, in this case, the patient's decreased LoC and history of vomiting warrant further investigation with imaging studies.