General Management

General management is as per APLS guidelines. [5]

Airway and breathing

Hypoxia alone may be responsible for reduced consciousness level. Oxygen should be administered. The seriously unwell infant may present with intermittent apnoeic spells associated with bradycardias and may look relatively ‘well’ in between.

Practically, GCS scoring can be difficult in the neonate/young child and repeated assessment is needed.

Consider intubation in a child with a GCS of 8 or less [1] or they have either of the following points [1]:

  • their GCS is deteriorating;
  • >40 mls/kg fluid resuscitation is needed;
  • status epilepticus;
  • signs of raised ICP.


Circulatory shock is suspected with a delayed central capillary refill time, tachycardia, tachypnoea, mottled cool extremities and poor peripheral pulses, which are often hard to feel in an infant.

Important: Treat shock with a fluid bolus of 10ml/kg of crystalloid or colloid, and assess for response. Repeat up to 40ml/kg but seek expert help before you approach this point.

Blood pressure: A blood pressure can be attempted but values vary for age. You need to use the correct sized cuffs and the procedure may distress the child. The BP should be reviewed against normal values for age.

Urine output: Ask the parents when the last wet nappy occurred. You would expect at least 3-4 wet nappies per day. Nappies can feel dry even if they have 40mls of urine due to high absorbency materials used in the nappy. If there is any doubt, weigh the nappy and compare to a dry one.


In addition to GCS and pupillary examination, [5], the fontanelle, tone and posture should be assessed. Blood glucose is also needed.

Febrile seizures occur from the age of 6 months to around 5 years of age. They should last less than 10 minutes and post-fit recovery should be relatively quick within 20 minutes, [12] unless rescue medication has been given. Delayed fit recovery may indicate a more sinister pathology. [11]

Non-convulsive status can occur and should be considered if the child’s GCS is not improving. Careful examination may reveal intermittent gaze deviation, nystagmus or other subtle signs to suggest a continued seizure. Use anticonvulsants as per protocol.


Front/back examination is required to look for:

  • A rash
  • Evidence of trauma
  • Drug use – check for powder residue