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Altered Mental Status in Children

Altered Mental Status in Children. Tintinalli’s Ch 131. Failure to respond to verbal or physical stimulation in a manner appropriate to the child’s developmental level Lethargic child: decreased awareness of self and the environment Decreased eye contact with family and staff

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Altered Mental Status in Children

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  1. Altered Mental Status in Children Tintinalli’s Ch 131

  2. Failure to respond to verbal or physical stimulation in a manner appropriate to the child’s developmental level • Lethargic child: decreased awareness of self and the environment • Decreased eye contact with family and staff • Stuporous child: decreased eye contact, decreased motor activity, and unintelligible vocalizations • Can be aroused by vigorous noxious stimulation

  3. Causes: toxic or metabolic states that deprive the brain of normal substrates • Supratentorial mass lesions: compress brainstem or diencephalon • Focal deficits with AMS • Neuro dysfunction is from rostral to caudal • Subtentorial mass lesions: prompt LOC • CN deficits, abnormal respiratory patterns (Cheyne-Stokes, hyperventilation, ataxic breathing)

  4. Metabolic encephalopathy • Decreased LOC before motor signs • Motor sign symmetric • Respiratory signs secondary to acid-base imbalance • Preserved pupillary reflex

  5. Clinical • Good history and PE • Coma scale • AVPU (GSC 15,13,8,3) • A—”alert” • V—”response to verbal stimuli” • P—”responsive to painful stimuli” • U—”unresponsive”

  6. Diagnosis • AEIOU TIPS • Alcohol, encephalopathy, insulin, opiates, uremia, trauma, infection, poisoning and seizure • POCT BG • CBC, CMP, UA, Urine Cx, BC, CSF, UDS, serum drug screen, EKG, CT head

  7. Hyponatremic children become symptomatic at plasma levels of approx. 120 mEq/L • Glucose • <60: palpitations, hunger, and sweating • <40: irritability, confusion, seizures, and coma • Intussusception: may present with initial symptom of AMS • Trauma: kids more likely to develop diffuse cerebral swelling

  8. Treatment • ABCs • Immobilize cervical spine for suspected trauma. • IV, O2, monitor • Provide fluid resuscitation, 20 mL/kg x3 as needed. • Administer antibiotics for suspected sepsis or meningitis. • Give naloxone for suspected opiate or clonidine overdose, 0.01 to 0.1 milligram/kg IV every 2 min.

  9. Treatment cont. • Administer flumazenil for suspected pure benzodiazepine overdose, 0.01 milligram/kg IV. • Give glucose for hypoglycemia, 2 mL/kg of a solution of 25% dextrose in water IV. • Avoid sodium bicarbonate for metabolic acidosis unless pH is <7.0. • Control seizures. • Prevent hypothermia with heat lamps during resuscitation, treat hyperthermia

  10. Disposition • Admit, usually to ICU • If transient and if reversible causes treated, may discharge home with 24 hour followup

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