Children presenting to hospital with decreased level of consciousness without a history of trauma can pose a diagnostic challenge given the wide variety of causes and the frequent lack of clues as to diagnosis. They can make significant demands on intensive and high dependency resources. A recent UK population based study found a 40% mortality associated with non-traumatic coma as defined by a Glasgow Coma Score (GCS) of 12 or less for at least six hours, with an estimated annual incidence of 30 per 100 000 children and 160 per 100 000 in the first year of life.¹

An evidence-based problem-orientated guideline has been produced over the last two years to aid the clinician in the decision-making processes.² The guideline was funded by a grant from the National Reye’s Syndrome Foundation following on from their workshop chaired by Dr Sue Hall in 2002. This information is freely available at www.nottingham.ac.uk/paediatric-guideline.

The guideline can be used on children presenting with a decreased conscious level (a GCS < 15/15 or responding only to voice, pain or not responding on the “AVPU” scale). The guideline does not apply to those with a known diagnosis with a management plan in situ, the newborn infant admitted to a neonatal intensive care unit, or the child with a learning disability whose usual GCS would be < 15.

The guideline focuses on the immediately identifiable and …