Abstract
On occasion, children may present to an urgent care with an emergent condition. This chapter will describe several common pediatric emergencies. Ultimately, the goal in any of these cases is stabilization of the patient and transfer to an emergency department.
Keywords
anaphylaxis, altered mental status, emergency, pediatric, respiratory distress, seizure, sepsis, shock
Altered Mental Status
1
Given that the differential diagnosis for altered mental status is quite broad, how can the major categories of potential etiologies be quickly recalled?
Remember the “tips on vowels.” The mnemonic AEIOU TIPS ( Box 52.1 ) is a useful tool for recalling the major categories of causes that should be considered in children presenting with altered mental status.
A: Alcohol, Abuse of substances
E: Epilepsy, Encephalopathy, Electrolyte disturbances, Endocrine disorders
I: Infection, Intussusception, Ischemia
O: Overdose, Oxygen deficiency
U: Uremia (and other metabolic causes)
T: Trauma (both known and abusive), Temperature abnormality, Tumor
I: Infection, Increased intracranial pressure, Insulin-related problems
P: Poisoning, Psychiatric conditions, blood Pressure (e.g., hypertension or hypotension)
S: Shock, Stroke, Space-occupying CNS lesion, Shunt problems
2
What are the most common causes of altered mental status in children?
The potential causes of altered mental status in children are numerous, including both structural brain disorders and systemic diseases. Trauma, infections, intoxications, and metabolic abnormalities are among the most common etiologies in children.
3
What are the signs of altered mental status in infants and young children?
Crying, inconsolability, irritability, lethargy, and/or poor feeding are common manifestations for patients in this age group.
4
What tools can be used to quantify a child’s mental status?
The Glasgow Coma Scale (GCS) and Alert, Voice, Pain, Unresponsive (AVPU) scale ( Table 52.1 and Box 52.2 ) are widely used and accepted tools that can be used to quantify and communicate a child’s neurologic status. These scales allow for the standardized evaluation, documentation, and communication of a child’s changing neurologic status over time.
| Score | Infant | Child | |
|---|---|---|---|
| Eye opening | 4 | Spontaneous | Spontaneous |
| 3 | To speech | To speech | |
| 2 | To pain | To pain | |
| 1 | None | None | |
| Best verbal response | 5 | Coos and babbles | Oriented, appropriate |
| 4 | Irritable, cries | Confused | |
| 3 | Cries in response to pain | Inappropriate words | |
| 2 | Moans in response to pain | Incomprehensible sounds | |
| 1 | None | None | |
| Best motor response | 6 | Moves spontaneously and | Obeys commands |
| purposefully | |||
| 5 | Withdraws to touch | Localizes painful stimulus | |
| 4 | Withdraws to pain | Withdraws to pain | |
| 3 | Abnormal flexion to pain | Flexion in response to pain | |
| 2 | Abnormal extension to pain | Extension in response to pain | |
| 1 | None | None |
A: Alert
V: Responsive to Verbal stimuli
P: Responsive to Painful stimuli
U: Unresponsive
5
What elements of the medical history are particularly critical to obtain for children presenting with altered mental status?
Focused, goal-directed questions pertaining to suspected etiologies are key to pinpointing the underlying cause of altered mental status. Caregivers should be asked specifically about the child’s current medications; medications and potentially toxic substances accessible in his/her environment; as well as any history of seizures, fever, headache, irritability, vomiting, changes in gait, and/or recent changes in behavior. Inquiring about a history of recent head trauma is extremely important. The absence of a history of trauma does not rule it out as an etiology, however, since many cases may be unwitnessed and/or unreported (including in cases of nonaccidental injury).
6
What is the initial approach for managing a child with altered mental status?
The initial management of any child presenting with altered mental status should begin with rapid assessment and support of the airway, breathing, and circulation. Oxygen (100% by nonrebreather face mask) should initially be administered to all patients until adequate oxygenation is assured. Because many of the causes of altered mental status in children require treatments with intravenous (IV) fluids or medications, intravenous access should be established in the vast majority of patients. A focused history and careful physical examination must be completed and should guide the selection of laboratory and imaging studies. Prompt transfer to the closest emergency department is of paramount importance.
7
What laboratory study should be obtained in all children with altered mental status?
A rapid bedside test for serum glucose should be performed in all children presenting with altered mental status. Additional laboratory studies—including arterial blood gas, serum electrolytes, and toxicology screens—may be useful, depending upon the patient’s history and physical examination findings.
8
What is the neuroimaging study of choice in a child with altered mental status?
Noncontrasted computed tomography (CT) of the brain is generally the initial neuroimaging study of choice for evaluating children with unexplained altered mental status. CT brain images can be obtained rapidly and reveal most structural abnormalities that may cause altered mental status, such as intracranial hemorrhage and mass lesions. Although magnetic resonance imaging (MRI) may provide higher-quality, more detailed pictures of the brain than CT, MRI scans are generally more difficult to obtain emergently, take longer to obtain, and often require sedation for young children.
9
What clinical clues should raise suspicion for toxic ingestion as the cause of altered mental status in a child?
Ingestion of a toxic substance should be strongly considered in children presenting with altered mental status of sudden onset without a preceding history of trauma or illness. A lack of close adult supervision, a chaotic home environment, as well as a history of previous ingestions by the child should raise a clinician’s suspicion for intoxication as the underlying etiology of altered mental status.
Anaphylaxis
10
What is the most common cause of anaphylaxis in children?
Food allergens represent the most common triggers of anaphylactic reactions among children, teens, and young adults. Other triggers may include medications, insect stings, blood products, immunotherapy, and radiocontrast media. In a significant proportion of cases, the cause is unidentified.
11
What are the signs and symptoms of anaphylaxis?
Anaphylaxis is a clinical syndrome that is highly likely when a patient meets any one of three diagnostic criteria listed in Box 52.3 .
Acute onset (within minutes to several hours) of signs/symptoms involving the skin, mucosal tissue, or both (e.g., generalized urticaria, itching or flushing of skin, swollen lips/tongue/uvula) AND at least one of the following:
- •
Respiratory compromise (e.g., dyspnea, wheeze/bronchospasm, stridor, hypoxia)
- •
Decreased blood pressure or associated symptoms of end-organ dysfunction (e.g., fainting, dizziness, incontinence)
At least two of the following occurring acutely after exposure to a likely allergen:
- •
Involvement of the skin and/or mucosal tissue
- •
Respiratory compromise
- •
Decreased blood pressure or associated symptoms of end-organ dysfunction
- •
Persistent gastrointestinal symptoms (e.g., crampy abdominal pain, nausea, vomiting, diarrhea)
Decreased blood pressure following exposure to a known allergen (low age-specific systolic blood pressure or a decrease in systolic blood pressure by 30% or more in infants/children)
12
What features of anaphylaxis are potentially life threatening?
Anaphylaxis has the potential to result in significant morbidity and even death. Upper airway obstruction (due to edema of the tongue, larynx, and other upper airway structures), cardiovascular collapse, and respiratory compromise due to bronchospasm are potential life-threatening complications.
13
What immediate interventions are required for patients with anaphylaxis?
Anaphylaxis is a medical emergency requiring immediate assessment and simultaneous aggressive support of the airway, breathing, and circulation. Intramuscular epinephrine is the first-line treatment for anaphylaxis; it should be given as early as possible (in the anterolateral thigh) to all patients presenting with the characteristic signs and symptoms. Any known or suspected trigger(s) (such as an intravenous medication or blood product) should be discontinued immediately. Patients with circulatory compromise should be placed in the supine position (or position of comfort if vomiting or in respiratory distress).
14
Can antihistamines and/or corticosteroids be used as an alternative to epinephrine in children with anaphylaxis?
Neither H 1 -receptor antihistamines (such as diphenhydramine) nor corticosteroids are first-line agents for treating anaphylaxis, due to a lack of evidence supporting their efficacy. While these medications are commonly used and may be beneficial for specific symptoms, they are not replacements for epinephrine and should serve only as adjuncts in treating anaphylaxis. Treatment with epinephrine should not be withheld or delayed due to the administration of these medications.
15
What laboratory studies are required to confirm the diagnosis of anaphylaxis?
None! Anaphylaxis is a clinical diagnosis, based primarily on a thorough history (including recent exposures) and recognition of the characteristic signs and symptoms. While elevated serum tryptase and histamine levels may support the diagnosis in some patients, these tests are not universally available, not useful in all patients, not performed emergently, and not specific for anaphylaxis. Their role in the diagnosis of anaphylaxis is limited and should never delay treatment.
16
What are the main benefits and contraindications to epinephrine use in patients with anaphylaxis?
Epinephrine use has been shown to decrease both hospitalizations and death among patients presenting with anaphylaxis. There is no absolute contraindication to its use in anaphylaxis. Therefore, it should be administered as the first-line agent for all patients presenting with anaphylaxis.
17
Can repeat epinephrine doses be given to children with anaphylaxis?
Yes! Intramuscular epinephrine doses may be repeated every 5–15 minutes for persistent or recurrent symptoms. In children with circulatory compromise and/or for those in whom multiple intramuscular doses have been ineffective, administration of intravenous epinephrine may be indicated.
18
How long should children be observed after being treated for anaphylaxis?
There is no “standard” time period for observing children after treatment for anaphylaxis. Length of observation should be determined for each child based upon factors including severity of illness at presentation, underlying risk factors, and ability of the family to access care. Children with mild to moderate symptoms resolving after treatment may be able to be discharged safely after 4–6 hours of observation, while those with more severe reactions should be monitored for a longer duration (8–24 hours, or even longer in particularly severe and/or complicated cases).
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