Altered Mental Status
TIPS from the vowels
- Trauma-head injuries or blood loss
- Insulin/hypoglycemia-both from insulin overdosing as well as Ketotic Hypoglycemia.
- Intussusception-the mental status changes can precede the abd pain
- Inborn Errors of Metabolism-especially when symptoms present in the first few months of life. Presenting sx often include vomiting or seizures. Hyperammonemia and metabolic acidosis are usually the two end states resulting in alteration of mental status. Get an ammonia level and a ABG with a lactate. Pyruvate and organic acids can be sent as well, but usually do not come back with alacrity.
- Psychogenic-a diagnosis of exclusion
- Seizures-consider non-convulsive status or postictal state
- Stroke, Shock, and other cardiovascular causes.
- Shunt-consider shunt problems in any child who has one
- Alcohol-both from the ETOH and resulting hypoglycemia
- Abuse-look for subtle physical signs
- Electrolytes-Consider CAH as a cause and look for ambiguous genitalia and hyperpigmented scrotum.
- Encephalopathy-Reye’s syndrome. Causes ALC by Hyperammonemia. Lead encephalopathy should be considered as well.
- Infection-meningitis, encephalitis, or infection elsewhere in the body
- Overdose/Ingestion-get a complete list of the medications in the household
- Uremia-from HUS or other causes of renal failure.
When diagnosing a simple febrile seizure, be sure that:
- The child is older than 6 months to 6 years
- Fever >38 C or history of recent fever
- The child has no underlying developmental or neurologic disease or history of afebrile seizures.
- The seizure is generalized (not focal in origin or during ictus).
- The seizure is single and of short duration (not more than 15 minutes, usually <2) and only once in 24 hours.
- The child quickly returns to his or her normal self.
- There is no identifiable underlying cause (apart from fever and a non-CNS infection).
Complex febrile seizures last longer than 15 minutes, occur in a series, have a focal onset, or have a prolonged postictal period. Two to four percent of all children will have a simple febrile seizure. Children who have had a febrile seizure have a 25%-50% chance of having a second event, usually within a year. Children at highest risk for recurrence are those with a first-degree relative who has had a febrile seizure, complex first febrile seizure, many episodes of fever,
or age younger than 15 months when the first event occurred. There is also an increased incidence of febrile seizures on the day of DT or pertussis vaccines or 1-2 weeks after MMR vaccine. Most important lab test is a bedside glucose. Cooling measures or antipyretics do not reduce the occurrence or recurrence of simple febrile seizures. Any witnessed seizure lasting longer than 5 minutes should be terminated with benzodiazepines. Patients with simple febrile seizures have similar rates of serious bacterial illness as matched patients with a fever but no seizure. AAP issued a practice parameter recommending that an LP be strongly considered in patients <12 months and strongly considered in 12-18 month olds. One large study of 2 month-15 year olds showed that no cases presenting as simple febrile seizure with no other abnormalities had meningitis. Factors that should argue for a tap include:
- History of irritability, decreased feeding, or lethargy
- Abnormal appearance or mental status changes
- Any physical signs of meningitis
- Complex features
- Any slow postictal clearing of mentation
- Pretreatment with Antibiotics
Patients with signs of increased intracranial pressure such as papilledema, “sunsetting” ocular motility, or obtundation should receive a CT before LP. Remember that hyponatremia is a more frequent cause of seizures in infants than in other age groups.
Etiology Of Newborn Seizures. First day of life Anoxia Hypoxia Trauma Intracranial hemorrhage Drugs Infection Hypoglycemia/hyperglycemia Pyridoxine deficiency Second and third day of life Sepsis Inborn errors of metabolism Trauma Hypocalcemia Hypoglycemia Hypomagnesemia Hyperphosphatemia Hyponatremia/hypernatremia Drug withdrawal Congenital anomalies Developmental brain disorders Benign familial neonatal seizures Hypertension Fourth day of life to 6 months of age Hypocalcemia Hyponatremia/hypernatremia Infection Drug withdrawal Inborn errors of metabolism Hyperphosphatemia Hypertension Congenital anomalies Developmental brain disorders Benign idiopathic neonatal seizures
dont bother pumping the shunt, it tells you nothing. get shunt series and head ct; you need both (Ped Emerg Care 18(5):337, October 2002.) Consult with a neurosurgeon to consider tapping shunt reservoir for pressure and fluid sample.
Patients present with signs of increased ICP: seizures, poor feeding, gaze palsies, diplopia, bulging fontanelle
fever, n/v, meningismus
may occur in children with long-term shunts; typically not life-threatening; no antisiphon device used in shunt, overdrains CSF; causes chronic headaches, resolves with administration of IV fluids (ventricle reexpands); CTsmall, narrow ventricles against proximal catheter; ventricles collapse due to overdrainage, create intermittent obstruction, increased intracranial pressure; symptoms relieved when ventricles reexpand; reported in 5% to 55% of patients with shunts, almost exclusively children; overshuntingmay lead to rigid ventricles due to lowered intracranial venous pressure, chronic congestion, and swelling of brain parenchyma; slit ventricles do not appear on CT; frequency <0.1%; treatmentshunts with antisiphon device (adult patients), secondary catheter, ventriculostomy or subtemporal craniotomy (Audiodigest)
acute noninflammatory encephalopathy mitochondrial dysfunction, notably in the CNS ASA predisposes if given during the course of a viral illness Elevated serum NH3, elevation of LFTs vomiting, lethargy, AMS, coma | | |