ALTERED MENTAL STATUS IN CHILDREN (8).pptx

assessment of altered mental status in pediatric age group

1. Altered mental status in children DR DAZLIN MASDIANA SABARDIN Senior lecturer & emergency physician Emergency department HCTM UKM

2. Neurologic Emergencies Can be benign or life threatening Medical history is important, including: Previous seizures Shunts Cerebral palsy Recent trauma or ingestions

3. Altered Mental Status Altered mental status (AMS) is a sign that the brain is not working properly. AMS in children often results in: change in behavior change in responsiveness to parents to surroundings 4

4. Altered LOC and Mental Status May be difficult to determine the underlying cause Run through PAT and ABCs quickly. Pay attention to disability and dextrose issues. Check glucose.

5. Children with AMS may appear Unusually agitated Combative Sleepy Difficult to rouse from sleep Totally unresponsive 6

6. Initial Assessment - AMS Findings include signs of Airway compromise Respiratory failure Hypoperfusion 7

7. Primary Assessment Use the Pediatric Assessment Triangle to form a general impression. Used with permission of the American Academy of Pediatrics, Pediatric Education for Prehospital Professionals, © American Academy of Pediatrics, 2000

8. Primary Assessment Appearance A child with a grossly abnormal appearance requires immediate life-support interventions and transportation.

9. Primary Assessment Work of breathing Reflects attempt to compensate for abnormalities in oxygenation, ventilation

10. Primary Assessment Circulation to skin Determine adequacy of cardiac output and core perfusion.

11. Hands-on ABCs Manage threats to ABCs as you find them. Steps are the same as with adults. Estimate child ’ s weight. Best method is pediatric resuscitation tape measure.

12. Hands-on ABCs Airway Determine whether airway is open and patient has adequate chest rise with breathing. If there is potential obstruction, position airway and suction as necessary.

13. Hands-on ABCs Breathing Calculate the respiratory rate. Auscultate breath sounds. Check pulse oximetry for oxygen saturation.

14. Hands-on ABCs Circulation Integrate information from PAT. Listen to the heart or feel pulse for 30 seconds. CRT

15. Hands-on ABCs Disability Use the AVPU scale or Pediatric Glasgow Coma Scale to assess level of consciousness. Assess pupillary response. Evaluate motor activity. Assessment of pain must consider age.

16. Hands-on ABCs

17. Hands-on ABCs Exposure Perform a rapid exam of the entire body. Avoid heat loss, especially in infants. Cover child as soon as possible.

18. Important Historical Elements Prodromal events Recent illness or infection exposures History of recent trauma Risk factors Medication in the house Social environment Vaccination Family history Developmental milestone Associated symptoms Constitutional GI Neurologic Cardiac Musculoskeletal Dermatologic Fever, weight loss Vomiting, diarrhea , abdominal pain Headache, gait changes, seizure, weakness Palpitation Head tilt Rash

19. Secondary Assessment Head Pupils Nose Ears Mouth Neck Chest Back Abdomen Extremities Capillary refill Level of hydration May include a full-body examination or a focused assessment

20. Secondary Assessment Attempt to take the child ’ s blood pressure on the upper arm or thigh. Minimal systolic blood pressure = 80 + (2 × age in years)

21. Body area Technique Findings Head Palpation Fontanelle palpation (in infants) Hematoma, fracture Fullness, depression, pulsations (reflects ICP) Eyes Eye position Reactivity of the pupils Funduscopic examination Midposition , deviated Constricted, dilated, symmetrical vs asymmetrical Papilledema, retinal hemorrhages Ears Inspection Bleeding, CSF drainage Nose Inspection Bleeding, CSF drainage Neck Palpation Auscultation Tenderness, spasm, stepoff , stiffness Bruits Breath Check for odor DKA: fruity smell Hepatic coma: musty smell Uremia : urine smell Alcohol Skin Inspection Jaundice, petechiae, purpura, pallor, cyanosis Chest Auscultation Signs of respiratory pathology Abdomen Palpation Hepatosplenomegaly, masses, evidence of intussusception

22. Reassessment Includes the following: PAT Patient priority Vital signs Assessment of interventions Reassessment of focused areas

23. Change in MS Mental status can improve in response to interventions. Mental status can also worsen if the child’s airway, breathing, or circulation worsens. If MS worsens, reassess ABC status. 29

24. Seizure

25. Seizures Result from abnormal electrical discharges in the brain May be predisposed; or result from: Trauma Metabolic disturbances Ingestion Infection

26. Seizures Physical manifestation of a seizure will depend on the area of the brain affected. Prognosis is linked to the underlying cause.

27. Seizures Types of seizures Generalized seizures involve the entire brain. Partial seizures involve only part of the brain. Simple partial seizures: no loss of consciousness Complex partial seizures: loss of consciousness

28. Seizures Assessment Give special attention to: Compromised oxygenation and ventilation Signs of ongoing seizure activity Status epilepticus: seizure lasting more than 20 minutes or two or more seizures without return to baseline

29. Focused History Seek information that can help hospital personnel determine the cause of the seizure, including: Length of seizure Specific seizure activity child's degree of responsiveness the location and characteristics of abnormal muscle movements loss of bladder or bowel control 35

30. The number of seizures Exposure to a toxic substance or medication Fever Head injury or recent trauma History of seizures or seizure disorder Medications being taking for a seizure disorder and time of last dose 36

31. Additional Focused History Consider possible causes of low blood sugar: Diabetes in children of all ages Alcohol poisoning Not eating due to illness in infants and toddlers 37

32. Detailed Physical Exam Examine the child for: signs of head injury a purplish skin rash that accompanies septic shock (hypoperfusion caused by infection) injuries to extremities caused by muscle movements during the seizure 38

33. Seizures Management Treatment is limited to supportive care if seizure has stopped by your arrival. For ongoing seizure, open airway. Suction for secretions or vomitus. Do not attempt ET intubation.

34. Seizures Management ( cont ’ d) Provide 100% supplemental oxygen; bag-mask ventilation as indicated for hypoventilation. Measure serum glucose; treat hypoglycemia. Consider administering a benzodiazepine. Diazepam, or midazolam

35. Seizures Management ( cont ’ d) If seizures do not stop, a second-line agent is necessary. Phenobarbital Phenytoin

36. Dangers of Status Epilepticus Low blood oxygen occurs due to lack of ventilation. Airway and breathing problems due to decreased muscle tone and function. Risk of aspiration due to vomiting. Brain damage or death can result if left untreated. 42

37. Status Epilepticus Treatment Because continuing seizures are more dangerous than brief seizures, they require more aggressive management. If the child is actively experiencing a seizure, the airway is unprotected. 43

38. Status Epilepticus Treatment If the child has uncontrolled muscle movements, support the head, maintain the airway. Protect from injury. 44

39. Post Seizure Treatment Place in recovery position, if there is no indication of trauma. Provide high concentration oxygen by non-rebreather face mask. Be prepared to suction. 45

40. Post Seizure Treatment If trauma is not suspected, place child in “sniffing” position and open airway. If the child vomits, position on left side to reduce risk of aspiration. 46

41. Post Seizure Treatment If there is history or evidence to suggest trauma to the head or neck Place the child in a neutral position. Immobilize the spine. 47

42. Post Seizure Treatment Manage the airway: Provide gentle suctioning as needed. Give high-concentration oxygen. If the patient shows signs of respiratory failure or arrest, begin assisted ventilation 48

43. Febrile seizure

44. Febrile Seizures Child must: Be age 6 months to 6 years Have a fever Have no identifiable precipitating cause Strongest predictor is a history in a first-degree relative.

45. Simple febrile seizures: Brief, generalized tonic- clonic seizures occurring without underlying neurologic abnormalities Complex febrile seizures: Longer, focal or occur with baseline developmental or neurologic abnormality

46. Meningitis

47. Meningitis Inflammation or infection of the meninges Viral meningitis: rarely life-threatening Bacterial meningitis: potentially fatal Always proceed as if bacterial meningitis Symptoms vary. The younger the child, the more vague.

48. Meningitis May cause sepsis Characterized by a rash Petechial Purpuric Courtesy of Ronald Dieckmann, MD

49. Meningitis Infection control is important. Signs and symptoms may include: Fever Altered mental status Bulging fontanelle Photophobia

50. Meningitis Perform a glucose check. Provide lifesaving interventions as needed Patient may need oxygen, airway management, and ventilation support.

51. Hydrocephalus

52. Hydrocephalus Results from impaired circulation and absorption of cerebrospinal fluid (CSF) Leads to increased ventricles and ICP Cerebral shunt often used to decrease ICP Ventriculoperitoneal (VP) shunts Ventriculoatrial (VA) shunts

53. Hydrocephalus Complications of cerebral shunts include infections, blockages, and overdrainage . Signs of malfunction include: Vomiting Headache Altered LOC Visual changes

54. Hydrocephalus Manage increased ICP. Transport immediately to a facility with pediatric neurosurgical capabilities.

55. Head injury

56. Closed Head Injuries Head trauma is common in childhood. Small number of children who appear to be at low risk may have an intracranial injury. Evaluate any child with head injury for signs of potential abuse.

57. Closed Head Injuries Epidural hematoma Hemorrhage into space between the dura and skull Almost exclusively caused by trauma Subdural hematoma Hemorrhage into space between dura and arachnoid membranes Suspect abuse until proven otherwise.

58. Diagram demonstrating types of intracranial bleeds, across (A) axial and (B) coronal views; EDH = epidural haematoma, SDH = subdural haematoma, SAH = subarachnoid haemorrhage, IPH = intraparenchymal haemorrhage

59. Closed Head Injuries Management includes stabilization of airway, breathing, and circulation. Perform frequent neurologic checks.