Case 24: Altered Mental Status, 2 Year Old

Front 1

Mnemonic to remember causes of altered mental status?

Back 1

AEIOU TIPS

A = alcohol, ingested toxins

E = epilepsy, encephalitis, endocrine, lytes

I = infection, insulin

O = overdose, opiates, oxygen deprived

T = trauma, temperature

I = insulin, infection

P = psychosis

S = stroke, shock, space occupying lesions

Front 2

Features of cholinergic drug ingestion?

Back 2

: "SLUDGE" (salivation, lacrimation, urination,defecation, GI motility, emesis)

Front 3

Features of anticholinergic ingestion? (diphenhydramine, tricyclicantidepressants)

Back 3

• Mydriasis (dilated pupils) "blind as a bat"
  
• Dry skin "dry as a bone"
  
• Red skin (flushed) "red as a beet"
  
• Fever "hot as Hades"
  
• Delirium and seizures "mad as a hatter"
  
• Tachycardia
  
• Urinary retention
• Ileus

Front 4

Features of sedative-hypnotic ingestion? (benzodiazepines, barbiturates)

Back 4

• Blurred vision (miosis or mydriasis)
  
• Hypotension
  
• Apnea and bradycardia
  
• Hypothermia
• Sedation, confusion, delirium, coma

Front 5

Signs of opiod ingestion?

Back 5

• Miosis (constricted pupils)
  
• Respiratory depression
  
• Bradycardia and hypotension
  
• Hypothermia
• Depressed mental status (sedation, confusion, coma)

Front 6

Signs of sympathomimetic overdose? (cocaine, amphetamines,pseudoephedrine)

Back 6

• Mydriasis
  
• Fever and diaphoresis
  
• Tachycardia
• Agitation and seizures

Front 7

Cholinergic physiologic effects?

Back 7

HR decreased

diaphoretic

pupils constricted

hyperactive abdo

Front 8

anticholinergic physiologic effects?

Back 8

HR high, temp high

skin dry

pupils dilated

abdo hypoactive

Front 9

sedative-hypnotic physiologic effects

Back 9

HR, BP, RR low

altered sensory exam

hypoactive bowel

Front 10

opio ingestion physiologic effects

Back 10

HR low, BP low, RR low, low temp

constricted pupils

hypoactive bowel

Front 11

Sympathomimetic ingestion physiologic effects

Back 11

HR, RR, BP, temp elevated

diaphoretic

dilated pupils

hyperreflexia

hyperactive bowel

Front 12

Common accidental ingestions in toddlers?

Back 12

iron

acetaminophen

Front 13

How to decontaminate follow toxic ingestion?

Back 13

consider: amt, timing, nature of substance, patient characteristics

several methods:

• syrup of ipecac
  
• activated charcoal
  
• gastric lavage
  
• cathartics
  
• hemodialysis
  
• hemoperfusion
  

Front 14

What occurs in nortriptyline toxicity?

Back 14

Ingestion of nortriptyline 2.5 mg/kg or higher in a 2-year-old will cause significant symptoms.Peak effect: 7-8 hours after ingestion.

Front 15

What occurs in Glipzide toxicity?

Back 15

One 10 mg tablet of glipizide can cause significant hypoglycemia in a 2-year-old.Peak effect: 2-3 hours after ingestion, but can last 24 hours.

Front 16

DDx of ingestion causing altered mental status and mydriasis?

Back 16

• Tricyclic antidepressant
  
• Selective serotonin reuptake inhibitor
  
• Antihistamine
  
• Decongestant
  
• Iron
  
• Beta-blocker
  
• Acetaminophen
  
• Aspirin
• Opioid

Front 17

TCA ingestion?

Back 17

Agitation, cardiac manifestations (especially hypotension), dilated pupils and dry, hot skinare classic findings in TCA ingestions.

Front 18

SSRU ubgestuib>

Back 18

serotonin syndrome (profuse sweaty skin, agitation, fever, mentalstatus changes, diarrhea, myoclonus, hyperreflexia, ataxia, and shivering).

Front 19

Antihistamine ingestions?

Back 19

similar to TCA

Front 20

Decongestant ingestion?

Back 20

tachycardia and hypertension, as well as agitation, sweating, fever,mydriasis and seizures.

Front 21

iron ingestion?

Back 21

severe abdo symptoms

followed by shock

Front 22

Beta blocker ingestion

Back 22

bradycardia

Front 23

Acetaminophen ingestion

Back 23

Initially presents with minimal symptoms (though gastrointestinal symptoms are notuncommon) followed by symptoms of liver toxicity.

Front 24

Aspirin ingestion

Back 24

Presents with agitation and tachycardia but there is no mydriasis.

Front 25

Opiod ingestion

Back 25

Causes sedation and constricted pupils (miosis)

Front 26

How to evaluate altered mental status?

Back 26

• glucose
  
• cbc
  
• lytes
  
• ekg
  
• calcium
  
• tox screen
  
• acetaminophen
  

Front 27

EKG findings in TCA toxicity?

Back 27

• irregular irregular rhythm
  
• p waves not distinctly seen
  
• widened qrs
  
• prolonged QT interval
  

Front 28

How to manage child with altered mental status?

Back 28

• CABs
  
• gather info
  
• order studies (depends on initial diff)
  

Front 29

What warrants immediate treatment?

Back 29

hypoglycemia

hypotension

tachycardia

Front 30

How to decontaminate treatments?

Back 30

• activated charcoal
  
• cathartic agent
  
• nasogastric lavage
  
• syrup of ipecac
  

Front 31

What else to do?

Back 31

consult home safety

Front 32

activated charcoal

Back 32

Indicated for ingestions not due to small molecules or heavy metals.Contraindicated in a patient with a loss of protective airway reflexes due to the risk ofaspiration; selective intubation should be considered in such cases.

Front 33

cathartic agents

Back 33

A single dose of a cathartic agent may be given with the initial dose of charcoal.

Front 34

Nasogastric lavage

Back 34

inconsistent benefit

Front 35

Ipecac

Back 35

not first line