Altered Mental Status Flashcards
Presentations of Altered LOC in infants
Irritability/excessive crying
Poor feeding
Increased sleepiness/lethargy
Causes of Altered LOC
Ingestion or other toxic exposure
Head injury
Sepsis
Shock - any kind
When to suspect toxic ingestion with altered LOC and no history of ingestion
No history or PEx findings of head trauma
Sudden onset of symptoms
Large number of children, including visitors in the home
Previous ingestions by patient or their siblings
Presence in the home of a sibling or multiple medications for behaviour control or seizures
Scales to quantify LOC?
AVPU
GCS
AVPU - 4 major levels of alertness (A) Alert (V) Responsive to verbal stimuli (P) Responsive to painful stimuli (U) Unresponsive
GCS- Eye, Verbal, Motor (4,5,6) Eye 4 - Spontaneous 3 - To speech/voice 2 - To pain 1 - None
Verbal
5 - Oriented, converses - coos/babbles
4 - Disoriented, converses - irritable/cries
3 - Inappropriate words - cries to pain
2 - Incomprehensible spounds - moans to pain
1 - None
Motor
6 - Obeys verbal command / Normal spontaneous
5 - Localizes to pain / Withdraws to touch
4 - Flexion withdrawal / Withdraws to pain
3 - Flexion decorticate / Abnormal flexion
2 - Extension decerebrate / Abnormal extension
1 - None
Immunization Mnemonic for DDx Altered LOC
DTaP
OPV
HIB
MMR
DTaP - Dehydration, Trauma, Poisoning
OPV - Occult trauma, Postictal/Postanoxia, VP shunt
HIB - Hypoxia/Hyperthermia, Intussusception, Brain masses
MMR - Meningitis/encephalitis, Metabolic, Reye’s syndrome and other rarities
When to consider a head CT for altered LOC
History of trauma
Any focal or lateralizing signs on PEx
Any suspicion of child abuse
When can you just observe a child with altered LOC?
Post seizure
Club drugs that cause altered LOC
Flunitrazepam (Rohipnol, roofies)
Gamma-hydroxybutyrate (GHB, liquid ecstasy, liquid X, lollipops)
Gamma-butyrolactone (GBL, blue nitro, firewater, G3, gamma G)
Ketamine (Vitamin K)
Lysergic acid diethylamide (LSD, acid)
Methamphetamine (meth, crystal)
Methylenedioxymethamphetamine (MDMA, ecstasy, X, XTC)
Medical devices that can malfunction to cause altered LOC
VP shunts
Baclofen pumps
Life threatening causes of Altered LOC
Epidural hematoma Cerebral edema Brain neoplasms Cerebral infarctions CSF shunt malfunction Meningitis Encephalitis Toxic ingestions Carbon monoxide poisoning Hypotension Hypoxia Sepsis Brain abscess - from sinusitis
What is ADEM and its features?
Acute Disseminating Encephalomyelitis Immuned-mediated inflammatory process Can happen after infection, after vaccination, or spontaneously Characterized by: - Irritability - Sleepiness - Confusion - Obtundation - Seizures - Coma
Need to do LP
Moderate leukocytosis with lymphocytic or monocytic predominance
MRI may show white matter lesions
Tips for performing LPs in older kids
Provide anxiolysis (IN Midaz - 0.3 mg/kg - max 10mg)
Use Lat/Maxilene to numb where you will put local
Anesthitize the space around L4/L5 prior to the LP
Can have patient sitting up or lying decubitus
Distraction with ipad etc can be helpful
RF for rabies
Young pets
Exposure to outside animals or shared drinking bowls
Travel to endemic areas- India, Phillipines
Can show densities in the basal ganglia
