Learning Objectives
>> List the five causes of altered mental status in pediatric patients.
>> Recognize the signs and symptoms of a pediatric patient with altered mental status.
>> Review the proper assessment techniques for pediatric patients with altered mental status.
Key Terms
Diabetic ketoacidosis (DKA): Altered level of consciousness due to an inability of the body to use glucose for metabolism.
Differential diagnosis: Any condition having similar signs and symptoms that must be considered during patient evaluation.
Encephalitis: An inflammation of the brain, primarily from infection that results from the bite of an infected mosquito.
Hematoma: A collection of blood in a localized area within an organ, space or tissue.
Hyperglycemia: Increased glucose in the blood, most often linked to diabetes mellitus; diabetic ketoacidoisis may result.
Hypoglycemia: Decreased glucose in the blood, usually called by excessive insulin or low food intake.
Intussusception: The telescoping of intestines causing a decreased blood supply to the affected segment.
Meningitis: Any infection or inflammation of the membranes covering the brain and spinal cord.
Primary survey: The initial, rapid examination of a patient or scene for life-threatening conditions.
EMS is dispatched to a residence for an “unresponsive child.” On arrival, a frantic mother is waiting at the door and directs the crew to the living room. EMS providers find an 8-year-old male who’s only responsive to deep pain. While one paramedic assesses the patient, their partner obtains a history from the mother. The mother states her child was complaining of a headache for the past week, and says it worsened earlier today. He’s an otherwise healthy child.
A full primary survey reveals that airway breathing and circulation (ABCs) are intact. The patient’s vital signs are a heart rate of 60, respiratory rate of 8, blood pressure of 160/120 and oxygen saturation of 90%. An IV is established, and a glucose check is administered, revealing a blood sugar of 95. The patient will only respond to deep, sternal rub.
Introduction
Patients with altered mental status (AMS) are some of the most challenging EMS calls. AMS in pediatric patients adds another level of complexity to the scenario. The younger the patient is, the less that they can tell us about what happened and what they’re feeling. EMS providers must remember that AMS isn’t the primary diagnosis. It’s always secondary to a cause, such as trauma, poisoning or a disease process.
Assessment
The primary survey for any patient should consist of the ABCs, with the addition of disability and exposure (ABCDEs). This assessment should be performed in a systematic approach. It’s vital to address the key findings that cause life-threatening challenges during the primary survey, but it can be difficult when caring for the patient with AMS because they may not appear critical. All providers, whether assessing a scene in the field or walking into a room in the emergency department (ED), get a first impression and can usually tell “sick” or “not sick.” This is easier said than done sometimes, so the primary survey must be performed on every patient, every time.
Often dispatch information isn’t clear, leaving the prehospital provider wondering what they’re going to walk into. Create an algorithm that can be reviewed briefly when you’re dispatched to any medical or trauma case involving a pediatric patient. This algorithm is crucial because the stress of knowing you’re about to care for a pediatric patient is enough to cause any provider to overlook key assessment findings.
Several tools can be used as guides to assist the provider. One of these tools is the American Heart Association’s (AHA) Handbook of Emergency Cardiovascular Care for Healthcare Providers. This excellent resource can provide critical information for the providers to use during their care. For example, how many of the 11 reversible causes can the provider recall when caring for a critical pediatric patient?1 If the providers are caring for their own child, you’d expect them to recall all 11, but that’s unlikely. So healthcare providers should use these tools to feel more confident in conducting assessments because they’re doing so.
When assessing the patient with AMS, the healthcare provider should never assume that they know the cause because your tunnel vision will lead you down a wrong path. One example is a case in which the EMS providers responded to a scene with mother who was altered with evidence of ethanol and drug use. She was breast-feeding an infant who was also altered and “sleepy” with no evidence of trauma. The crew assumed it was due to the mother’s intoxication; however, the cause of the infant’s AMS was actually due to head trauma after the child was dropped numerous times throughout the day.
ABCDE
The two parts of the assessment that are easily overlooked in pediatric patients with AMS are disability and exposure. The goal in the disability assessment is to check the neurological status. This starts by checking the alert, verbal stimuli, painful stimuli and unresponsiveness scale and pupils. For the patient with chronic medical problems, this may be difficult to define; the provider may find it useful to ask a reliable caregiver to advise what’s different.
When assessing exposure, the emergency provider must look at the patient’s entire body, including the posterior surfaces. Failing to properly expose a patient with AMS can cause the EMS provider to miss the source.
Everyone wants to be an expert when it comes to the basics; properly exposing a patient to complete the primary survey is a big part of that. Remember that the only way to get proficient at pediatric patient assessment is to do an assessment the same way every time, regardless of whether you’re examining an adult or pediatric patient.
The last part of the assessment of the pediatric patient with AMS is obtaining a complete set of vital signs. These patients should be placed on a full monitor to obtain heart rate, respiratory rate, blood pressure and pulse oximeter reading. The use of capnography is recommended to assess air exchange and work of breathing.
Although not all EMS providers carry thermometers, a basic assessment of whether the patient feels hot or cold should be done. Glucose isn’t a vital sign, but it’s vital that patients with AMS have a glucose obtained. Correcting hypoglycemia early in the field can decrease morbidity and mortality.
Causes
Chairman of Emergency Medicine at Vanderbilt University Medical Center and JEMS Editorial Board member Corey Slovis, MD, FACEP, is notorious for teaching that there are five causes for everything. Well, for patients with AMS, there are five main causes to examine.2 Although the specific causes for pediatric patients may differ from those for adults, the general categories hold true.
1. Vital Sign Abnormalities
Hyperthermia/hypothermia: As previously stated, obtaining a full set of vital signs should be a priority in these patients because vital-sign abnormalities are one of the top causes of AMS. Many kids become altered when they have a fever. They can become lethargic or irritable, making examining them difficult. For the patient who’s severely altered and febrile, the concern for overwhelming sepsis or meningitis is higher.
Your concern should be whether the patient is suffering from a heat stroke if the patient has been outside in a hot environment and presents with hyperthermia and AMS. If this patient is suffering from heat stroke, the EMS provider should immediately cool the patient by undressing them and using ice packs to the axillae and groin.
Hypothermia is also a cause of AMS. For patients who are found outside during the winter months or who have suffered trauma and been undressed, care should be taken to ensure that the patient is kept as warm as possible. A patient begins to be coagulopathic and their blood begins to not clot well when their temperature drops below 96° F.3
Hypoxia: Who knew that the pulse oximeter (SpO2) would change how we practice as much as it has? You could argue that there are patients who don’t need an SpO2 reading, but every patient with AMS needs to be monitored continuously with one.
Patients with increased work of breathing, wheezing, trauma to the chest or hypoxemia should be addressed quickly and placed on 100% oxygen via a non-rebreather mask. Placing a child with AMS on 100% oxygen is always the right thing to do–except in rare cases, such as the child with cyanotic congenital heart disease.
Hypovolemia: The most common cause of hypovolemia causing AMS is acute blood loss. EMS providers should realize, however, that hypotension is a late sign in pediatric patients. Once the child is hypotensive, they’re in decompensated shock and are at an increased risk for morbidity and mortality. Also, hypovolemia should be considered in patients with a resting heart rate above baseline for their age. Normal pediatric systolic blood pressure = (age x 2) + 90.1
Tachycardia/bradycardia: Although not common causes, tachydysrhythmias and bradycardia can both cause AMS in pediatric patients. Infants can present with fussiness or unresponsiveness secondary to supraventricular tachycardia. If the patient has a heart rate above 220 and it isn’t variable, a 12-lead ECG should be performed to look for this; if found, it should be treated appropriately with vagal maneuvers and/or adenosine.
2. Toxic/Metabolic
Hypo/hyperglycemia: Every patient with AMS, whether an adult or child, should have their glucose checked. Too often EMS providers make excuses for not sticking for a glucose because the patient is a child. That excuse isn’t valid and can’t be tolerated. If a patient is hypoglycemic, then the brain is also hypoglycemic and is at risk of permanent damage. Hypoglycemia should be corrected rapidly in the prehospital setting, either through oral glucose if the patient is awake or through IV dextrose if the patient is altered.
>> Infants: Administer 5 cc/kg of D10W;
>> Children: Administer 2—4 cc/kg of D25; and
>> Adolescents: Administer 1 cc/kg of D50.
Hydrogen ion excess (acidosis): This can be a cause for AMS, but unless your service carries a blood gas machine, you won’t be able to know whether the patient is acidotic. The most common condition leading to acidosis and AMS is diabetic ketoacidosis (DKA); this is treated with fluids and an insulin drip in the hospital setting.
Toxic (overdose): All too often children find medicine that isn’t theirs and ingest it. In the toddler age group, this is often because they find pills (that look like candy to them) on the floor, left on a table or night stand or get into the unlocked medicine cabinet. In the adolescent population, they’re usually ingesting medicines in an attempt to get high. Knowing what medicines are in the house, even if it means putting them all in a bag and bringing them to the ED, can be invaluable.
Caregivers often forget about medicines that are in their cabinet and deny that the patient could ever have ingested anything. For patients with AMS and vital-sign changes, such as apnea or bradycardia, administering naloxone 0.1mg/kg is appropriate and will not present untoward side effects. If the patient doesn’t respond to this, increase the dose to 0.2mg/kg up to a total of 10mg to look for patient effect.
Another toxic source that can cause AMS, especially in the winter months, is carbon monoxide (CO). Every patient with suspected CO poisoning should receive 100% oxygen en route to the hospital.
3. Structural
Trauma: Trauma is the number one cause of death in children and is always something to consider in a patient with AMS. Head injuries due to non-accidental trauma (child abuse) should always be in your differential diagnosis, especially for infants and toddlers.4
Healthcare providers are now doing a better job of recognizing head injuries causing concussions in older children and adolescents.5 These injuries aren’t apparent on a computerrized axial tomography (CT) scan like a subdural or epidural hematoma, but they should still be considered.
Seizure: Pediatric seizures are a common reason for EMS to transport a patient. Whether the patient has epilepsy or is having just a simple febrile seizure, these patients can present with AMS. No matter the cause, all seizure patients should have a glucose checked by EMS (see hypoglycemia above). Not all seizure patients present with generalized tonic clonic activity. Patients with partial seizures may present with AMS and automatisms, such as eye blinking, tongue thrusting or rhythmic movements of just one extremity. This is why it’s imperative for the healthcare provider to fully assess all patients with AMS.
Stroke: The proper recognition of pediatric stroke patients is on the rise. Although it’s much less common than in the adult population, patients with such predisposing risk factors as sickle cell disease or clotting disorders are at risk. Just as in adults, timely recognition of a stroke is the key to minimizing morbidity and mortality. Crews must also consider the possibility of a child involved in a fall having sustained a concussion or multiple concussions over a short time period, which can result in significant damage.
Intussusception: In toddlers who have been vomiting or had diarrhea, intussusception can also cause AMS. Intussusception is the telescoping of intestines causing a decreased blood supply to the affected segment. This is usually manifested as intermittent, severe, crampy abdominal pain.
Often the child will be seen drawing their legs up to their abdomen in pain. The patient may pass a bloody stool, but this is usually a late finding. In some patients, this condition can cause AMS. Intussusception is treated with an air reduction enema and sometimes requires surgery.
4. Infectious
Many infectious causes can lead to AMS in the pediatric patient. The three most common causes are meningitis, encephalitis and overwhelming sepsis. Providing these patients with high-flow oxygen and monitoring vital signs are the key to a successful transport. As with any patient with infectious signs and symptoms, the healthcare provider must protect themselves through the use of gloves and a mask when the situation dictates.
5. Psychiatric
Although uncommon in most pediatric patients, this is a diagnosis of exclusion and one that shouldn’t be routinely entertained in the prehospital environment.
Conclusion
The 8-year-old boy from our opening case is transported from home with AMS after his worsening headache. His physical exam is notable only for a response to deep sternal rub. The patient’s mom reports that he hasn’t suffered any trauma and has never had a headache like this before. He’s placed on 100% oxygen via a non-rebreather mask and is immediately transported to the closest hospital.
On arrival, the patient is intubated for airway protection and healthcare providers obtain a CT scan. The CT revealed a mid-brain hemorrhage leading to a stroke. It was later discovered that this was secondary to an arteriovenous malformation.
As with every patient, a systematic approach to the pediatric patient with AMS is the key to success and will help the prehospital provider ensure the patient gets the best care possible. JEMS
References
1. American Heart Association. Handbook of Emergency Cardiovascular Care for Healthcare Providers. American Heart Association: Dallas. 2010.
2. Corey Slovis, MD. Five Causes of Altered Mental Status. Emergency Medicine Lecture Series. Vanderbilt University School of Medicine.
3. Tsudei B, Kearney PA. Hypothermia in the trauma patient. Injury. 2004;35(1):7—15.
4. Limmer D, O’Keefe M, Grant H, et al. Emergency Care, 10th Edition. Brady: 775, 2005.
5. Donofrio C, Campbell R. (2011) Recognizing Concussion and Treating Postconcussion Syndrome. In Rehab Management. Retrieved Nov. 30, 2011, from www.rehabpub.com/issues/articles/2011-09_04.asp.
Read “EMS Providers Can Identify Child Abuse” from October JEMS on jems.com/journal to learn more about signs and symptoms of child abuse.
This article originally appeared in January 2012 JEMS as “Clear the Fog: The challenges of patient who can’t explain their condition.”
