This presentation reviews the management of pediatric patients with altered mental status and highlights some of the key points via four brief cases.

3. Normal AMS Coma
GCS 15 GCS <15 but >3 GCS 3

5. • ABC(DE)s
– Airway support
– Oxygen
– IV access
• Vitals are vital
– For instance, in rising ICP vitals change sequentially
• Bradycardia (early sign of herniation in children)
• Hypertension
• Widened pulse pressure
• Cushing’s triad: late finding of brainstem dysfunction
– HTN, bradycardia, irregular respirations

6. • Rapid bedside glucose test
• Electrolytes including BUN/Cr
• Blood gas
• CBC
• Blood Culture if infection suspected
• Liver panel including ammonia
• Urine drug screen

7. • Seizure drug levels
• Thyroid studies
• Coags in sepsis and ICH
• Co-Oximetry for CO or MetHgb
• Fancy metabolic labs
• EKG in ingestions with cardiac effects
(TCAs, BP meds)

8. • Does every kid with AMS need a head CT?
– All with an acute coma of unknown etiology
should get one
– Also in:
• Signs of elevated ICP
• Trauma
• Focal findings
• Suspected shunt malfunction
• Unsupervised child

9. • Which patients with AMS need an LP?
– Suspected meningitis/encephalitis
– To confirm subarachnoid hemorrhage in a
negative CT
• These patients also need coags in addition to the CT
before they get an LP
– An opening pressure is helpful

11. • MRI
– Consider in a stroke (after the head CT)
• EEG
– New protocol will allow Neuro to set up EEG in the
ED for status epilepticus

12. • Trauma and hemorrhage
– Consult Neurosurgery
– Protect airway if GCS ≤8
– Interventions for elevated ICP
• Hypertonic 3% Saline 6-10ml/kg over 5-10 minutes
• Mannitol 0.25-1g/kg over 10-20 minutes
• Elevate HOB with head midline
• Maintain homeostasis (temperature, oxygen, BP etc.)
• Don’t hyperventilate unless herniation is imminent

13. • Seizures
– Postictal patients should improve in 2-3 hours
• Simple febrile seizure generally normal by 1 hour
• If lethargic or irritable >1 hour even after antipyretics be
worried about meningitis/encephalitis
– Focal defects indicate a focal CNS lesion until proven
otherwise
• Get a head CT
– Drug levels, electrolytes
– Empiric Tx for meningitis/encephalitis
– Manage seizures with benzo x2, fosphenytoin then
phenobarb

14. • Infection
– Antimicrobials as early as possible
– If focal findings or seizure get a head CT to r/o a
focal CNS infection
– CSF analysis
• Pleocytosis in encephalitis is mild (<500 cells/mm3) with
normal glucose and protein
• CSF in HSV encephalitis contains RBC in 50%
• Bloody/xantochromic CSF with elevated opening
pressure, but no pleocytosis suggests SAH

15. • Tumors
– Consult Onclogy and Neurosurgery
– Interventions to mitigate increased ICP
– Steroids may help – but ask the consultant first
• Vascular disease (stroke)
– Hemorrhagic: Treat seziures and elevated ICP, address
coagulopathy
– Ischemic: supportive care, PICU and Neurology, heparin
• Hydrocephalus and CSF Shunt Problems
– Ask a Neurosurgeon nicely to replace the shunt

16. • Hypoxia
– Give oxygen
• Cardiovascular abnormalities
– Hypotension: Treat BP to optimize CBF
– Arrhythmia: Heart doctors are helpful here
– Hypertensive encephalopathy: Goal to lower BP by
20% in the first hour, labatelol first, then drip of
labatelol or nicardipine

17. • Intoxications
– Give Narcan if the patient has miosis or suspected
narcotic (or clonidine) ingestion
– Avoid giving flumazenil to block benzos, as you won’t
be able to treat a subsequent seizure if you give it
– Get urine tox, APAP and ASA, etOH
– EKG in cardioactive meds
• Can toxic ingestions lead to unequal pupils?
– No

18. • Metabolic alterations
– Treat hypoglycemia
• Neonates D10W 1-2ml/kg IVP (10g/100ml)
• Children D25W 1-4ml/kg IVP (25g/100ml)
• Adults D50W 25g IVP
• Hypo/Hyperthermia
– Raising temperature too quickly can be bad
– <32oC internal and external warming

19. • Calm and supervised environment
• Mechanical restraints
• Medications
– IM Geodon
• Children 10mg
• Adolescents & Adults 10-20mg
– 69% of 20mg doses exceeded the
calming therapeutic effect
– IM Haldol 2-5mg q4-8 hrs
• Give with IM Cogentin 1mg
– PO/IV Ativan 0.05 mg/kg/dose - max 2mg
• PO effective within 30 minutes

20. • Stabilize patient (ABCs) get IV and test at least rapid
glucose (consider ISTAT)
• Unless you are absolutely sure that the cause is
extracranial get a head CT
– Mass lesion, bleed, ventricle size, intracranial HTN
• Await other labs and prepare for LP
– Measure opening pressure

21. ABCDE + Bedside glucose + IV
Supplemental O2
Fluids
Cooling/warming
Labs + correct aberrant glucose/lytes
Antibiotics if any suspicion of infection
Head CT
LP
Neuro Consult

22. • Assuming no head trauma occurred in the absence of
corroborating history
• Neglecting to secure the airway before getting a head CT
• Hyperventilating an intubated patient to a pCO2 well below
35 mmHg
• Not sedating the paralyzed/intubated patient
• Believing that a toxic ingestion has not occurred just
because the urine drug screen is negative

25. • 7yo F with acute onset AMS
– Woke up normally, then went back to bed shortly
thereafter
– Upon reawakening she was confused and disoriented
– 2d ago ‘low grade fever’ and headache
– Yesterday NBNB emesis x3
• Normal PMH, vaccines UTD, no recent shots
• No ingestions, no trauma

26. AMS in triage – Medical Team called
VS: T 38.7 HR 140 RR 25 BP 92/58
GEN: confused
HEENT: NCAT, EOMI, PERRLA, TM wnl, sweet smelling breath
NECK: no LAN, patient winced when head passively moved
CV: tachycardic, no murmur, 3-4 sec cap refill, 2+ peripheral
pulses
PULM: CTAB, no wheezes or crackles
GI: soft, NTND, no masses, no HSM
SKIN: no rashes
NEURO: MAEW, GCS 13 (-1 V & -1 E)

27. What are your top 3 diagnoses?
What do you want to do?
ISTAT: 7.54/28/+1, Glucose 186, HCO3 24, Na 133
Urine 3-4 wbc/hpf, LE and NIT negative
Liver, ammonia normal
Renal with Na 134
CBC wbc 34 86% segs H/H 11.7/35.2 Plts 520
Utox ASA and Acet negative
CXR normal
Head CT mild diffuse cerebral swelling, no herniation or acute
hemorrhage

28. • LP
– Glucose <20
– Protein 433 mg/dL
– RBC 642 WBC 1266
– Gram stain: WBCs and gram + cocci in pairs and chains
• Diagnosis
– Bacterial meningitis
– Started ceftriaxone and vancomycin
– Admitted to PICU
– Ultimately grew S. pneumo in CSF, but B/C negative

30. • 12 yo M fell backwards off a diving board
ladder 4-5 feet onto concrete
– Questionable LOC, now tearful and very anxious
– EMS: C collar and backboard
• PMH: neck injury about 6 weeks ago when he
ran into some bleachers. In a ‘neck brace’ due
to that injury for a short time

31. Trauma eval
VS: T 37.2 HR 63 RR 29 BP 132/63 SAT 100%
GEN: WDWN, tearful, anxious confused
HEENT: 1-2 inch area of soft tissue swelling over right occiput.
No laceration. PERRLA, EOMI, TM wnl, mmm
NECK: Negative for midline C spine pain
CV: RRR, nl S1 and S2, 2+ pulses, 2 sec cap refill
PULM: CTAB
GI: soft, NTND, no masses, no HSM
SKIN: no rashes
NEURO: MAEW, GCS 14 (-1 V)

32. According to the latest head injury guidelines
should this child get a head CT?
• Absolutely!
– LOC + GCS 14
– There is a Head Injury Tool in Epic that can help
assess these risk factors
• https://vimeo.com/36792246

33. Hemorrhage into a pre-existing temporal
lobe arachnoid cyst

34. • Ultimately admitted to PICU after
Neurosurgical consultation
• No emergent surgery
• Subsequent Neuroimaging stable
• Other than occasional headaches he has done
quite well

36. • 21mo F w/ sickle cell disease
• 1d of fever at home and 2d of mild URI Sx
• No vomiting, diarrhea, cough or difficult
breathing
• Developed progressive lethargy throughout
the evening

37. Medical Team
VS: T 38.6 HR 154 RR 34 BP 90/56 SAT 96% RA
GEN: lethargic, responds to painful stim, cries for mommy
HEENT: NCAT, PERRLA, EOMI, TM wnl, mmm
CV: tachycardic, nl S1 and S2, 1+ peripheral pulses, 2+ central
pulses, 5 sec cap refill
PULM: CTAB but grunting
GI: distended, non tender, spleen tip palpable 4cm below LCM
SKIN: pale and sallow, no rashes
NEURO: MAEW, GCS 13 (-1 M -1E)

38. What complication of sickle cell are you worried about?
What do you want to do?
Multiple pIV attempts unsuccessful so IO placed in R
proximal tibia
ISTAT: 7.22/44/-9, Glucose 168, HCO3 18.5, H/H 3.1/10
CXR no focal disease

39. • Over the next 30min lethargy progressed and perfusion
worsened
– She had received 40ml/kg NS and Rocephin
• Labs came back
– CBC wbc 27 60% segs H/H 3.3/9.3 Plts 61
– PTT 64.8 PT 25.5 INR 2.18
– Renal unremarkable, aside from glucose 151
• Eventually she was noted to have extensor posturing
with eyes deviated to left
– Ativan given, which abated the seizure

40. • With progressive decline in MS we intubated
via RSI
• Though T&S not available she got 5ml/kg O- pRBC
• Head CT showed no hemorrhage or mass effect, no
edema
• Admitted to PICU with the dual diagnoses of…
– Splenic sequestration and Sepsis

42. • 6 y/o M brought to ED by aunt for confusion
and AMS
• He was fine until after dinner
• Acting ‘weird’ and picking at ‘bugs’ in the air
• No PMH, no meds or allergies
• He was at the aunt’s house all day long
– Being watched by the aunt and his 13 y/o cousin

43. Evaluated in the D Pod
VS: T 37.0 HR 146 RR 18 BP 112/62 SAT 100% RA
GEN: alert, confused, making repeated pinching motions in air and on
clothes, diaphoretic
HEENT: NCAT, pupils symmetrically dilated (8mm) and reactive, EOMI, TM
wnl, mmm
CV: tachycardic, nl S1 and S2, 2+ pulses, nl perfusion
PULM: CTAB
GI: normal
SKIN: normal
NEURO: MAEW, nonfocal motor and sensory, answers questions
somewhat appropriately (knows his name, and where he is), seems
confused

44. What toxindrome is this consistent with?
What do you want to do?
• EKG NSR
• Renal normal
• APAP and ASA normal
• Utox + for amphetamines

45. • Oh, and by the way, his aunt later volunteered
that her daughter (the patient’s erstwhile
babysitter cousin) has ADHD
• The patient was later found to have ingested an
unknown amount of her Ritalin
– Admitted to telemetry and ultimately his mental
status and VS normalized
• Ironically he was also diagnosed with scabies…

46. Take home points about patients with Altered Mental Status
1. Altered mental status is caused by an underlying disease
process
2. Always check glucose
3. If you can’t exclude an intracranial process, or the child was
recently unsupervised get a head CT
4. Do an LP if you don’t have another cause after CT, and to
evaluate for infection, or if you suspect SAH
5. Even with a past history of mental health illness acute onset
psychosis is more commonly associated with an underlying
medical cause