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| *ECG | | *ECG |
| *Neuroimaging | | *Neuroimaging |
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| == DDx ==
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| Alcohol Intoxication
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| *Hypoglycemia may coexist
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| Acid-Base and Metabolic Disorders
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| *DKA
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| **Wt loss, polyuria/dipsia, vomiting, AMS
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| *Hypercapnia - primary lung/neuro dz
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| *Hepatic failure - nausea, fatigue,
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| inborn errors
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| Arrhythmia and other cardiogenic disorders
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| *Aortic stenosis
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| *Tamponade
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| ENCEPHALOPATHY Hypertensive encephalopathy may occur in children at diastolic pressures of 100 to 110 mm Hg
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| ENDOCRINOPATHY Addison disease present with nausea, vomiting, abdominal pain, weakness, malaise, hypotension, and mental status changes, including psychosis
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| Infants with congenital adrenal hyperplasia may present in an acute salt-losing, volume-depleted hypotensive crisis or with virilization characterized by ambiguous genitalia and cortisol insufficiency also manifested as hypoglycemia.
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| ELECTROLYTE IMBALANCES Hyponatremic children become symptomatic at plasma levels of approximately 120 mEq/L. Manifestations include anorexia, headache, nausea, vomiting, irritability, weakness, cramps, disorientation, seizures, and altered mental status. Hypernatremia results in muscle weakness, irritability, seizures, and altered mental status. Disorders of calcium, magnesium, and phosphorus present with neuromuscular signs, including weakness, tetany, seizures, and apathy
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| HYPOGLYCEMIA
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| Adrenergic signs of palpitations, hunger, and sweating are seen at levels of <60 milligrams/dL. Irritability, confusion, seizures, and coma occur at levels of 40 milligrams/dL (see Chapter 137, Hypoglycemia and Metabolic Emergencies in Infants and Children). Infants and children are prone to develop ketotic hypoglycemia with fasting, especially with infections in early infancy
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| <br/>Altered mental status may be the initial and predominant symptom of intussusception.
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| OPIATE INGESTION
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| UREMIA In children with chronic renal failure, neurologic dysfunction may develop secondary to stroke, hypertension, or metabolic derangements. Encephalopathy occurs in more than one third of patients with chronic renal failure and is manifested by headache, irritability, cognitive derangement, and seizures. Hemolytic-uremic syndrome is the most common cause of acute renal failure in childhood.
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| <br/>TRAUMA Children with blunt head trauma are more likely than adults to develop diffuse cerebral swelling, increased intracranial pressure, and altered mental status without extracerebral or intracerebral collections of blood
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| TUMOR
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| Supratentorial and infratentorial tumors may present abruptly with altered mental status, fever, or meningismus after an intratumor hemorrhage
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| <br/>THERMAL EXTREMES Extremes of body temperature also may lead to central nervous system dysfunction Children who develop body core temperatures of >41°C (105.8°F) develop headache, weakness, and dizziness followed by confusion, euphoria, combativeness, and altered mental status.
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| <br/>INFECTION Infection is more common as a cause of altered mental status in children than in adults. The incidence of bacterial meningitis and septicemia is highest in early infancy and is considerably higher throughout childhood than in adulthood. Bacterial meningitis should be high on the differential diagnostic list for a febrile child with altered mental status. Unless there are contraindications to lumbar puncture, examination of CSF should be considered in lethargic, febrile children. Patients with encephalitis have fever and headache and may have signs of meningeal irritation or neurologic deficits. Herpesviruses, arbovirus, rotavirus, and Epstein-Barr virus are among the most common viral agents associated with encephalitis. Encephalitis may occur in the course of mycoplasmal illness, shigellosis, Lyme disease, or cat-scratch disease.18 Visceral larva migrans may produce encephalopathy in the young.
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| A brain abscess may create signs and symptoms suggestive of encephalitis. Children with a brain abscess have fever and headache that precede changes in presentation and consciousness. Presenting symptoms also include generalized or focal seizures. Risk factors for brain abscess include sinusitis, otitis media, mastoiditis, soft tissue infections of the face, cyanotic congenital heart disease, immunodeficiency, comminuted skull fracture, ventriculoperitoneal shunt, and IV drug abuse.19
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| Any systemic infection associated with vasculitis or the production of vasodepressant toxins and accompanied by shock may lead to altered mental status secondary to cerebral hypoperfusion.
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| Altered mental status may be caused by exogenous intoxicants such as ethanol, ethylene glycol, methyl alcohol, paraldehyde, salicylates, anticholinergics, antihistamines, cholinergics, opiates, carbamazepine, clonidine, sedative-hypnotics, amphetamines, cocaine, cannabis, nicotine, carbon monoxide, hydrocarbons, and multiple psychotropic drugs within the categories of selective serotonin reuptake inhibitors, mood stabilizers, and antipsychotics. Ingestion of household and beauty products also may cause altered mental status.
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| == Treatment == | | == Treatment == |
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| *Control seizures | | *Control seizures |
| *Prevent hypothermia, treat hyperthermia | | *Prevent hypothermia, treat hyperthermia |
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| Assess airway, breathing, and circulation. Immobilize cervical spine for suspected trauma. Initiate continuous pulse oximetry; consider capnometry; administer oxygen. 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. 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.
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| If there is clinical suspicion of opiate or clonidine overdose, administer a narcotic antagonist. The recommended dosage for naloxone is 0.01 to 0.1 milligram/kg IV every 2 minutes until the desired effect is achieved or a total dose of 2 milligrams has been given. Any dose, if successful, may be repeated as necessary to maintain narcotic reversal. Flumazenil (Mazicon), a benzodiazepine antagonist, may be used for pure benzodiazepine ingestion in an otherwise healthy child. The dose is 0.01 milligram/kg IV, with cardiac monitoring established.
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| == See Also ==
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| == Source == | | == Source == |
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| Tintinalli | | Tintinalli |
| [[Category:Peds]] | | [[Category:Peds]] |
