Altered Mental Status in Children

1
Altered Mental Status in Children

• Tintinallis Ch 131

2

• Failure to respond to verbal or physical
  stimulation in a manner appropriate to the
  childs 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)
• Aalert
• Vresponse to verbal stimuli
• Presponsive to painful stimuli
• Uunresponsive

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
• lt60 palpitations, hunger, and sweating
• lt40 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 lt7.0.
• 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