Altered Mental Status

Milton Tenenbein, MD, FRCPC,

FAACT, FAAP
I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed
in this CME activity.

I do not intend to discuss an

unapproved/investigative use of a commercial
product/device in my presentation.
 Case 1
January, four year old little girl
Brought to the ED by Dad who just
returned from a business trip
Mom is home with the same GI bug
Your patient has headache, nausea and
vomiting
HR 136 RR 28 BP 90/50 Temp 37 C
Saturation 99% (room air)
 Progression
She appears tired and mildly dehydrated
from vomiting
You give her a 20 mL/kg fluid bolus
She eats a popsicle
Looks better!
 Progression
While taking out the IV
You make a little small talk
So do you have any pets?
She starts to sob inconsolably!!
FLUFFFFY
Oh! Fluffy was found in full
arrest on their furnace!
 Synthesis
Cat dead
Mom sick too
Dad OK
Child rapidly improves

Likely Environmental
Most Likely Environmental
Culprit?

Carbon Monoxide
 Carbon Monoxide

What tests?
Carboxyhemoglobin concentration
What about O2 Saturation?
Patients was 99% (room air)
Carbon Monoxide Poisoning
Remember colorless and odorless
Why did our patient get better in the
hospital?
Why wasnt Dad symptomatic?
What do you do as the health care
provider?
 Case 2
10 month old little boy, brought by EMS in
December 2010
Presents with increased work of breathing
for 1 day and vomiting x 4
Past medical history: asthma, gastro-
esophageal reflux, developmental delay
 Physical Exam
HR 186, RR 72, BP 92/56, Temp 38.3C,
Sat 100%
Mental Status: appears dazed and sleepy
HEENT: sunken eyes, dry lips
Chest: rapid breathing, almost panting,
equal BS bilaterally, no audible wheezing
Abdomen: soft, slightly distended
Skin: cool, mottled extremities; no
evidence of trauma
 Progression
Albuterol nebulizer started by nurse
Intravenous access obtained
Electrolytes sent
20 mL/kg bolus initiated
Continuous monitoring
Ill-appearing!
 Evaluation
Airway: patent
Breathing: almost panting
Circulation: capillary refill (> 4 sec)
Disability/Dextrose: 168 mg/dL
Exposure: no bruising
iSTAT 8: Na, K, Cl, bicarbonate, serum
urea nitrogen and creatinine
 Differential Diagnosis?
Infection
Trauma
Toxin
Neoplasm

Infection or Ingestion are most likely

Acute onset
Fever
 Febrile:
Ingestion Vs. Ingestion

Which is more likely?

 Toxicologic Fevers
Drug Class Mechanism Examples
-adrenergic agents vasoconstriction amphetamine; cocaine
anticholinergics impair sweating antihistamines; belladonna
cyclic antidepressants anticholinergic imipramine; amitriptyline
neuroleptics hypothalamic chlorpromazine;
dysfunction haloperidol
SSRI block serotonin fluoxetine; peroxetine;
uptake sertoline
MAOI serotonin isocarboxazid; phenelzine;
catabolism tranylcypromine
salicylates uncouple ox phos aspirin
 Toxicological Hyperpyrexia
Syndromes

Neuroleptic Malignant Syndrome

Serotonin Syndrome
Malignant Hyperthermia
 More Information

Electrolytes Cap Gas

Sodium 148 pH 7.03
Potassium 4.8 pO2 71
Chloride 110 pCO2 8
Bicarbonate 7 HCO3 8
BD -25
 Anion Gap Acidosis
(Na + K) - (Cl + HCO3) you may omit the K

Normal values: < 11 mEq/L

Our patient 148 (110+7) = 31 mEq/L

 MUDPILES
Methanol
Uremia
Diabetic ketoacidosis
Paraldehyde
Iron, Isoniazid
Lactic acidosis
Ethylene glycol
Salicylates
 Wait a Minute!

Anion Gap Acidosis + Fever = ???

Severe Sepsis
Salicylate Poisoning
 Progression
More thorough history suspecting an
inborn error of metabolism??
Miscarriages?
Medications?
Ingestions?
Over the counter preparations?
Only Maalox for his GE reflux
 Tell Me More About the
Maalox
Well it was on sale at the pharmacy and
we had a coupon. I asked his
gastroenterologist if I could use the
Maalox Maximum Strength and she said
okay
I am giving 2 tablespoons every 4 hours
 Poison Control Center
1-800-222-1222
Maalox Maximum Strength contained
bismuth subsalicylate 525 mg/15ml
Receiving 30 ml each 4 hours,
235-320 mg/kg for days
His salicylate level was 98 mg/dL
Most Important Intervention???

Hemodialysis
 Pharmacokinetics
Salicylate is rapidly absorbed from the GI
tract (predominantly the jejunum)
Metabolized by the liver (first order
kinetics: glucuronidation, oxidation,
glycine conjugation)
In an overdose, switches to zero order
kinetics, so at increased doses the half-life
is greatly increased up to 30 hours
 Mechanism of Action
Activation of the respiratory center of the
medulla
Uncoupling of oxidative phosphorylation
leads to metabolic acidosis, hyperpyrexia,
fluid loss
Inhibition of tricarboxylic acid leads to
metabolic acidosis
 Clinical Manifestations
Intoxication may be acute, chronic or acute-on-
chronic (our patient)
Fatal salicylate intoxication may occur with as
little as 3 grams in children
Death is usually from severe CNS toxicity and
loss of function of the cardiorespiratory center
Hallmarks of salicylate overdose include:
hyperpnea, metabolic acidosis, and tachycardia.
Severe overdose can cause altered mental
status, coma, non-cardiac pulmonary edema and
death.
 Case 3
Previously well 4 year old boy
On way back from New York (car trip)
Difficult to arouse in back seat of car
VS: T 37C HR 90, RR 6-14, BP 90/60
Three sibs are fine: ages 1, 3 and 6 yrs
FHx: Mom, history of anxiety, Dad nil
Parents say no meds available to him
Arrives at Community Hospital
Very sleepy, difficult to arouse, no external
evidence of trauma
RR 6-12, with stimulation higher
HR 64-66
BP 82/54
Pupils 1-2mm
Approach?
 Approach

Airway
Breathing
Circulation
Disability/Dextrose
Exposure
 Differential Diagnosis
CNS Depression - AEIOU TIPS
Alcohols
Epilepsy: partial, complex, status, or post-ictal
Ingestion
Opiates
Uremia (chronic, not acute)

Trauma or CNS mass

Infection (systemic or CNS)
Psychiatric (not in small children)
Sugar/metabolic problem
 Questions
1. What is the relative likelihood of a toxic
ingestion?
2. If a toxin is involved, which are likely?
3. CT scan? LP?
4. Should this child be admitted or observed
in the Emergency Department?
 Further Questioning
Anyone even occasionally use any
medications?
Well, Mom has panic attacks
Keeps her medicine in the glove
compartment
 Clonidine (in the glove
compartment)
Naloxone! 0.4 mg given at
Community Hospital without any
appreciable effect!
Transported by helicopter to us
HR 80, RR 6, responds to
stimulation, nasal trumpet
Poison Control Center
1-800-222-1222
Advises higher dose naloxone
(1 mg intravenous push)
Immediate result! Awake!!
PICU mocks the admission!!
 Effects of Overdose
Heart rate; bradyrhythmias
Shallow or slow breathing
Body temperature
Drowsiness coma
Reflexes, weakness, irritability
Constricted, pinpoint pupils
Seizures
 Case 4
6 week old baby girl
First PED visit: spitting up
Second visit: spitting up and fussy
Third visit: spitting up, sleepier than
usual and while in PED develops a fever
HR 138 RR 46 BP 64/48 Temp 38.5 C
 Progression
Full Sepsis workup
Peripheral WBC 22,000
Platelets 623,000
Hgb 7 gm/dL
Lumbar puncture: RBCs in CSFnot
clearingtubes 1 to 4
Baby has a brief seizure!
CT scan
CT Scan
Retina
 Abusive Head Trauma
Most common cause of morbidity and
mortality in the physically abused child

Average age 3-8 months

May be no external evidence of injury

 Practice Change
When assessing a child with altered mental
status consider a non-purposeful ingestion
and dont dismiss the possibility of it being
an over the counter medication.
 Practice Change
Evaluation a Child with CNS Depression
AEIOU TIPS
Alcohol Trauma or CNS mass
Epilepsy Infection (systemic or CNS)
Ingestion Psychiatric (not in small
children)
Opiates
Sugar/metabolic problem
Uremia (chronic)
Practice Change

Fever Infection