History
The key questions on presentation should explore prodromal events leading to decreased consciousness with reference to the wide differential diagnosis: any recent illness and length of symptoms [1,2]:
| Category | Symptoms |
|---|---|
| Shock | Abdominal pain, excessive diarrhoea and vomiting may suggest fluid loss or surgical cause. [6] |
| Sepsis | Vomiting, headache, fever, rash and infectious exposure may suggest infection. However recent antibiotic use may mask classical presentations of meningitis in the early phase. A detailed history is recommended. |
| Trauma | Trauma may or may not be evident particularly in the case of a non-accidental injury. [7] Inappropriate responses or inconsistencies and delays in seeking help arouse suspicion of non-accidental injury. |
| Intracranial | History of ear pain is suggestive of otitis media; ask about frontal headaches, facial pains and purulent nasal discharge which are suggestive of sinusitis. Intracranial extension can occur. |
| Epilepsy | There may be a family history or prior seizures or a history of neuro developmental delay |
| Poisoning | No history may be given. Examination may give clues to potential source. [8-10] |
| Raised intracranial pressure | If there is a past history of neurosurgery or neuro-developmental problems, check whether a shunt has been inserted or if there is a history of hydrocephalus. Make enquiries regarding recent head injuries. |
| Metabolic | Recent weight loss, polydipsia or polyuria may suggest a metabolic cause. A family history should be sought including if any consanguinity which may suggest inborn errors of metabolism. |
| Hypertension | A review of medication history may give a clue to the cause. |
General Questions
Exploring developmental milestones, past medical, travel, immunisation and family history including infant deaths further guides management.
Learning Bite
Non-accidental injury may be behind the cause of reduced consciousness, consider child protection issues. [1,7]