Confirmation
Pediatric Altered Mental Status
June 19, 2019
Hosts:
Gordon Minaker, Primary Care Paramedic and Medical Student with the UBC Medical Program
Kaela Richardson, Respiratory Therapist and Medical Student with the UBC Medical Program
Guests:
Dr. Garth Meckler, Pediatric Emergency Physician, Associate Professor and Division Head of Pediatric Emergency Medicine at BC Children’s Hospital and the University of British Columbia, Pediatric Advisor for the BC Emergency Health Services
Episode Description:
In this episode we discuss pediatric patients with altered mental status (AMS) in a prehospital setting. Main points of discussion are: patient presentation, key points of history and physical assessment, a review of common causes of altered mental status in kids and appropriate prehospital management.
Show Notes:
Altered Mental Status as per the BCEHS Handbook
"Altered mental status in children is characterized by the failure to respond to verbal or physical stimulation in a manner appropriate to the child's developmental level."
Assessment
AVPU for Quick Assessment of Mental Status
- Awake
- Verbal
- Pain
- Unresponsive
ABCDE Approach to Assessment & Treatable Causes of AMS
|
Age |
Hypoxia, hypercapnia, low respiratory rate |
|
Circulation |
Hypotension, hypertension, cardiac arrhythmias |
|
Disability |
Increased intracranial pressure, toxidromes, head injuries |
|
Exposure |
Trauma, hyperglycemia, hypoglycemia |
Common Causes of Pediatric AMS
- Hypoglycemia
- Infection
- Poisonings/Overdoses
- Trauma
- Seizures/Postictal state
Simple vs Complex Febrile Seizures*
|
Simple Febrile Seizure |
Complex Febrile Seizure |
|
|
Age |
6 mos - 5 yrs |
Any |
|
Frequency |
Single seizure in 24 hrs |
Multiple seizures in 24 hrs |
|
Nature |
Generalized |
Focal or generalized |
|
Duration |
Lasting < 15min |
Can be prolonged |
|
Recovery |
Post-ictal with return to baseline and normal neurological exam |
Post-ictal, may not full return to normal if multiple seizures |
*Richer, L, Mikrogianakis, A, Helman, A. Emergency Management of Pediatric Seizures. Emergency Medicine Cases. November, 2015. https://emergencymedicinecases.com/emergency-management-of-pediatric-seizures/. Accessed June 7th, 2019
B.R.U.E. Criteria
“Brief Resolved Unexplained Event” occurs in infants < 1 yr of age & include ≥1 of the following:
- Absent, decreased, or irregular breathing
- Cyanosis or pallor
- Altered level of responsiveness
- Marked change in muscle tone (hypertonia or hypotonia)
Note: Infants must be otherwise well and back to baseline state of health for incident to be considered a BRUE.
Prehospital Management of Pediatric AMS
Basics
- ABCDE approach
- Vital signs
- Blood glucose
Seizures
- Anticonvulsants
Note: Benzodiazepines have the potential to cause respiratory depression and airway management should be anticipated.
Hypoglycemia
- Treat blood glucose < 4.0 mmol/L.
- Glucagon onset is 10-30 minutes; consider waiting for IV dextrose if ALS crew is en route.
Overdoses/Poisonings
- Suspect environmental cause if more than one person is affected.
- Naloxone if respiratory depression +/- pinpoint pupils.
Note: Naloxone is not appropriate for patients on chronic opioids or infants of mothers with an opioid addiction.
Pearls
- While riding to a pediatric call, familiarize yourself with normal ranges for pediatric vital signs using the BCEHS Handbook guidelines.
- Non-convulsive seizures can present with lip smacking, blank stares.
- Consider an empiric dose of anticonvulsant if patient is unresponsive with an elevated heart rate.
- Ask caregivers about all medications in the home and survey the scene for possible causes of AMS.
- Bring in any evidence of poisonings or overdose, including pill bottles for pill count.
- Altered mental status is the primary presentation of marijuana edible ingestion.
References:
Pediatric Altered Mental Status - BCEHS Handbook
https://handbook.bcehs.ca/treatment-guidelines/pediatric-guidelines/altered-mental-status/
Altered Mental Status, Overview - BCEHS Handbook
Poison Control
https://www.dpic.org/
Toll Free 1-800-567-8911
Vancouver 604-682-5050
Brief Resolved Unexplained Events & Evaluation of Lower-Risk Infants - American Academy of Pediatrics
https://pediatrics.aappublications.org/content/pediatrics/137/5/e20160590.full.pdf
Emergency Management of Pediatric Seizures - Emergency Medicine Cases
https://emergencymedicinecases.com/emergency-management-of-pediatric-seizures/
Translating Emergency Knowledge for Kids (TREKK)
Initial Assessment and Treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) Approach - International Journal of General Medicine
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3273374/
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Email: podcast@bcehs.ca