24: 2-year-old female with altered mental status

Question 1

The mnemonic comprised of the vowels (A, E, I, O, U) and TIPS is often helpful in remembering the causes of altered mental status:

Answer 1

Alcohol, ingested toxins
Epilepsy, encephalitis, endocrine, electrolytes Infection (meningitis/sepsis)
Overdose, opiates, oxygen deprived
Uremia (renal failure)
Trauma, temperature
Insulin
Psychosis
Stroke, shock, space occupying lesions

Question 2

Cholinergic

organophosphates

Answer 2

-Miosis and blurred vision
-Increased gastric motility (nausea, vomiting, diarrhea)
-Excessive tearing, salivation, sweating and urination
-Bronchorrhea and bronchospasm
-Muscle twitching and weakness
-Bradycardia
-Seizures and coma
Mnemonic: “SLUDGE” (salivation, lacrimation, urination, defecation, GI motility, emesis)

Question 3

Anticholinergic

diphenhydramine, tricyclic antidepressants

Answer 3

Mydriasis (dilated pupils) “blind as a bat”
Dry skin “dry as a bone”
Red skin (flushed) “red as a beet”
Fever “hot as Hades”
Delirium and seizures “mad as a hatter” Tachycardia
Urinary retention
Ileus

Question 4

Sedative-hypnotic

benzodiazepines, barbiturates

Answer 4

Blurred vision (miosis or mydriasis) Hypotension
Apnea and bradycardia
Hypothermia
Sedation, confusion, delirium, coma

Question 5

Opioids

codeine, morphine, heroin

Answer 5

Miosis (constricted pupils) 
Respiratory depression 
Bradycardia and hypotension 
Hypothermia
Depressed mental status (sedation, confusion, coma)

Question 6

Sympathomimetics

cocaine, amphetamines, pseudoephedrine

Answer 6

Mydriasis
Fever and diaphoresis
Tachycardia
Agitation and seizures

Question 7

Typical Accidental Ingestions in Toddlers

Answer 7

iron and acetaminophen

Question 8

Immediate treatment to address tachycardia, hypotension, hypoxia, and hypoglycemia should include

Answer 8

• -A bolus of 20 cc/kg normal saline to treat tachycardia and hypotension
• -Administration of oxygen
• -A bolus of 10% or 25% solution of dextrose (D10 or D25).

Question 9

In the setting of a suspected ingestion, laboratory studies can provide information to guide both diagnosis and management.

Answer 9

• glucose
• electrolytes, blood gas
• EKG
• Calcium
• Tox screen
• Acetaminophen

Question 10

A 2-year-old female with normal birth and developmental history presents with increased agitation and decreased arousability. Her father suffers from chronic pain secondary to a back injury, and her mother found an open container of pills on the bed. Vitals reflect bradycardia, bradypnea, hypotension, and slight hypothermia. On physical exam, she exhibits somnolence, constricted pupils, hypoactive bowel sounds, and hyporeflexia. What substance was most likely ingested?

Answer 10

Hydromorphone is correct. Opioids such as hydromorphone can cause respiratory depression, bradycardia, hypotension, hypothermia, constipation, nausea, vomiting, sedation, confusion, and/or miosis.

Question 11

A 2-year-old male presents to the ED with a 5-hour history of hyperactivity, fever, and sweating. His BP is 160/90 mmHg, HR 130 bpm, RR 30 bpm. On exam, he has dilated pupils, cool skin, and hyperreflexia. What is his most likely accidental medication ingestion?

Answer 11

Pseudoephedrine

Ingestion of a sympathomimetic like pseudoephedrine stimulates the beta and alpha adrenergic receptors, causing elevated HR, RR, BP and hypothermia along with diaphoresis, dilated pupils, hyperreflexia, and hyperactivity.

Question 12

You are working in the pediatric ED when a 3-year-old girl, Jenny, presents with altered mental status for the past six hours. Her mother reports that the babysitter called her at work today after Jenny started acting agitated and “looking very sick.” The mother reports “she feels so warm, I think she has a fever and has become dehydrated.” On exam, the patient is agitated and anxious with dilated pupils. Her skin is warm and dry. Vitals reveal tachycardia and hypotension. You suspect the child may have accidentally ingested one of her mother’s medications. An overdose of which of the following medications could cause Jenny’s symptoms?

Answer 12

TCA toxicity presents with agitation, tachycardia, hypotension, dilated pupils, and hot, dry skin from the anticholinergic effects of TCAs.

Question 13

A 2-year-old male is brought into the ED by his mother because of vomiting and altered mental status. He has pinpoint pupils and seems to be drooling and sweating uncontrollably. His heart rate is 60 bpm, his respiratory rate is 45 bpm, and he seems to have difficulty breathing. Which ingestion is the most likely cause of his symptoms?

Answer 13

Organophosphates cause cholinergic effects, such as miosis, sweating, lacrimation, salivation, urination, increased gastric mobility (vomiting, diarrhea), muscle twitching, bronchospasm, bradycardia, and seizures. A good mnemonic is SLUDGE (salivation, lacrimation, urination, defecation, GI mobility, emesis).