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Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
Recognize most common causes of Altered Mental Status in Childhood
Address management and understand when to transport the child
This condition is not a disease, but a condition caused by a variety of diseases or clinical states, it is a medical emergency to understand the cause
Examination of the child1) ABC’s
2) Neurologic ExamCranial NervesDeep Tendon ReflexesSensoryMotor? CerebellarMental Status
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
Neurologic ExamCranial Nerves
Eye movementsDoll’s EyesCold Water Calorics
Neurologic ExamCranial Nerves
Pupillary light reflex
Neurologic ExamCranial Nerves
Corneal Sensation
Neurologic ExamCranial Nerves
Gag
Neurologic ExamCranial Nerves
Respiratory Drive
Motor Exam
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
Reticular activating systemMidbrainPonsMedulla
Definitions:
Lethargy – Difficult to arouse
Obtundation – Responsive to stimuli other than pain
Stupor – Responsive only to pain
Coma – Unresponsive to pain
Encephalopathy – diffuse disorder
Altered state of consciousnessAltered cognition or personalitySeizures
EncephalitisEncephalopathy plus CSF pleocytosis
The treehole mosquito (Aedes triseriatus) transmits
the virus that causes La Crosse encephalitis
Motor Response Example ScoreCommands Follows simple commands 6Localizes Pain
Pulls examiner's hand away when pinched 5
Withdraws from Pain
Pulls a part of body away when pinched 4
Abnormal Flexion
Flexes body inappropriately to pain 3
Abnormal Extension
Body becomes rigid in an extended position when examiner pinches him 2
No Response Has no motor response to pinch 1
Eye-Opening .Spontaneous Opens eyes on own 4
To VoiceOpens eyes when asked to in a loud voice 3
To Pain Opens eyes when pinched 2No Response Does not open eyes 1
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
Verbal Response
Oriented
Carries on a conversation correctly and tells examiner where he is, who he is, and the month and year 5
Confused Conversation
Seems confused or disoriented 4
Inappropriate Words
Talks so examiner can understand him but makes no sense 3
SoundsMakes sounds that examiner cannot understand 2
No Response Makes no noise 1
Causes of Lethargy, Stupor and Coma:
Intracranial HematomaCerebral EdemaPostictal StateHypoxic Brain InjuryHypoglycemiaToxin IngestionMeningitis/Encephalitis
Evaluation of Lethargy, Stupor and Coma:
Intracranial Hematoma CT Scan
Cerebral Edema CT Scan
Postictal State Hx of Sz, EEG
Hypoxic Brain Injury Hx of Hypoxic event
Hypoglycemia Chemistries
Toxin Ingestion Tox Screen/ Medication levels
Meningitis/Encephalitis CBC/ LP
Acute confusional state with impaired alertnessAlerting functions
Overworking or underworkingDifficulty focusing, shifting or sustaining attention
Formal definition includes:Fluctuating confusionDisturbed sleep wake cycle
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
4 general causes
1. Primary intracranial disease
2. Systemic disease affecting CNS
3. Exogenous toxins
4. Drug withdrawal
Onset is within days3 general variants of activity and alertness
1. Hypoalert‐hypoactive2. Hyperalert‐hyperactive3. Mixed
– May cycle rapidly between hyperactive and hypoactive.
Altered sleep wake cycles“Sundowning”Tremor, tachycardia, diaphoresis, outbursts, delusions, hallucinations may occur
Diagnosis primarily by historyPhysical exam to look for causesAdditional testing to identify a cause
Labs: CMP, CBC, UA+/‐ lumbar puncture
Radiology: CXR and head CTMMSE
Treat the underlying causeInfections: pneumonia, UTI, meningitis, sepsisMetabolic: hypoglycemia, electrolytes, hepatic, thyroid disorders, ETOH, or drugsNeurologic: CVA, TIA, seizure, intracranial hemorrhage or massCardiopulmonary: CHF, MI, PE, hypoxiaDrug related: Narcotics, sedatives, muscle relaxants, antiemetics, digoxin
SedationHaloperidolLorazepam
Confinement or restraints as appropriate
Admit unless rapidly reversible cause is identified
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
State of reduced alertness and responsiveness from which you cannot be aroused
Glasgow Coma ScaleMotor, verbal, eye opening
GlobalHypoglycemia, hypoxia
CNSBrainstem diseaseBilateral cortical disease
Unilateral should not present as coma
Secondary to compression of the brainstem
Primarily uncal vs. central
Medial temporal lobe compresses brainstemDecreased responsiveness going into a comaIpsilateral pupil dilated and nonreactive
Progressive loss of consciousness
Decorticate posturing
Irregular respirations
Pediatrics Grand Rounds 9 July 2010
University of Texas Health Science Center at San Antonio
Localized vs. generalizedCerebral blood flow constant with MAP of 50‐100 mm of HgCPP = MAP – ICPCushing reflex of hypertension and bradycardia
Coma secondary to hemispheric hemorrhage may still have localizing featuresPupillary, muscle, and cranial nerve exam to determine central vs. focalPupillary response generally preserved in toxic metabolic coma
Stabilization diagnosis and treatment overlapABC’sLab,+/‐ LPCT headExamination
Focal vs. diffuse
C‐spine immobilization if trauma suspectedPediatric coma commonly ingestion, infection, or abuseSeizures
Coma s/p seizure activity“electromechanical dissociation of the brain and body”
Reverse identifiable causesGlucose
Thiamine prior if alcoholicNaloxone
If signs or history of opioid useFlumazenil
Only recommended if history of benzo use not as routine.