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Pediatric Altered Level of Consciousness

Pediatric Altered Level of Consciousness. Terms. Resus Cocktail. Basics A B C IV, O2, Monitor FS EKG CXR Blood Gas +/- US. Resus Cocktail. Basics A B C IV, O2, Monitor FS EKG CXR Blood Gas +/- US. Quiz. Pediatric Resuscitative Drugs. Cardiac Resuscitative (PALS) Drugs.

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Pediatric Altered Level of Consciousness

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  1. Pediatric Altered Level of Consciousness

  2. Terms

  3. Resus Cocktail Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US

  4. Resus Cocktail Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US

  5. Quiz

  6. Pediatric Resuscitative Drugs Cardiac Resuscitative (PALS) Drugs Epinephrine – 0.01mg/kgAtropine - 0.02mg/kgBicarb – 1-2mEq/kg Etomidate – 0.3mg/kgKetamine – 0.5-2mg/kgRocuronium – 1-1.5mg/kgPRBCs – 10-20ml/kgFFP – 10-20ml/kgPlatelets – 5-10ml/kgDextrose – 1ml/kg D50 Airway Drugs Blood Products Hypoglycemia

  7. Quiz

  8. Pediatric Resuscitative Drugs Cardiac Resuscitative (PALS) Drugs Epinephrine – 0.01mg/kgAtropine - 0.02mg/kgBicarb – 1-2mEq/kg Prostaglandin E1 – 0.1mcg/kg/min IV/IOEtomidate – 0.3mg/kgKetamine – 0.5-2mg/kgRocuronium – 1-1.5mg/kgPRBCs – 10-20ml/kgFFP – 10-20ml/kgPlatelets – 5-10ml/kgDextrose – 1ml/kg D50 Airway Drugs Blood Products Hypoglycemia

  9. Follow-up Quiz

  10. Pediatric Resuscitative Drugs Cardiac Resuscitative (PALS) Drugs Epinephrine – 0.01mg/kgAtropine - 0.02mg/kgBicarb – 1-2mEq/kg Prostaglandin E1 – 0.1mcg/kg/min IV/IOEtomidate – 0.3mg/kgKetamine – 0.5-2mg/kgRocuronium – 1-1.5mg/kgPRBCs – 10-20ml/kgFFP – 10-20ml/kgPlatelets – 5-10ml/kgDextrose – 1ml/kg D50 Airway Drugs Blood Products Hypoglycemia

  11. Brief Focused Toxicologic Exam (after ABCs) • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone

  12. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US

  13. 4 A’s

  14. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US Standard AMS labs, imaging (CT Head)

  15. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US Standard AMS labs, imaging (CT Head) +/- Empiric Antibiotics (If LP, perform w/in 2 hours of Abx)

  16. Quiz

  17. Toxicology – Ingestion or Exposure • Activated charcoal - <1hr presentation • 0.5-1g/kg ages under 12 • 25-100g adolescent/adult • Contraindic: can’t protect airway • Naloxone • 0.1mg/kg up to 20kg • Can give 2mg for >20kg • Flumazenil • Ativan • 0.05-0.1mg/kg (max 4mg) • AnticonvulsantsKeppra/Pheny/Phosphen/Phenobarb • 20mg/kg • Bicarbonate Drip • Hemodialysis

  18. Hyponatremia • Diluted formula, endocrine abnormalities (adrenal), drugs Treatment: • Correction aim <12mEq/day • Concern for Central Pontine Myelinolysis if over correct • 3% HS – reserved for actively seizing • 2ml/kg over 10-60min, can x3 • Raises ~2mEq; aim ~5mEq

  19. Quiz

  20. Neurology Seizures Space Occupying Lesion CVA anti-NMDA receptor antagonist • Autoimmune Encephalitis • Molecular mimicry, Abs bind to physiologic receptors; can be from underlying tumor (ovarian teratoma) • Seizures, movement disorders, psychiatric symptoms, catatonia • Often mistaken for suspected poisoning • LP/CSF: Send anti-NMDA receptor antibodies • Treatment: • Tumor resection if present, immunotherapy, steroids • Earlier detection/treatment = better outcomes

  21. Neurology Seizures Space Occupying Lesion CVA anti-NMDA receptor antagonist • Autoimmune Encephalitis • Molecular mimicry, Abs bind to physiologic receptors; can be from underlying tumor (ovarian teratoma) • Seizures, movement disorders, psychiatric symptoms, catatonia • Often mistaken for suspected poisoning • LP/CSF: Send anti-NMDA receptor antibodies • Treatment: • Tumor resection if present, immunotherapy, steroids • Earlier detection/treatment = better outcomes

  22. Neurology Seizures Space Occupying Lesion CVA anti-NMDA receptor antagonist • Autoimmune Encephalitis • Molecular mimicry, Abs bind to physiologic receptors; can be from underlying tumor (ovarian teratoma) • Seizures, movement disorders, psychiatric symptoms, catatonia • Often mistaken for suspected poisoning • LP/CSF: Send anti-NMDA receptor antibodies • Treatment: • Tumor resection if present, immunotherapy, steroids • Earlier detection/treatment = better outcomes

  23. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US Standard AMS labs, imaging (CT Head) +/- Empiric Antibiotics (If LP, perform w/in 2 hours of Abx)

  24. Neurology Seizures Space Occupying Lesion CVA anti-NMDA receptor antagonist • Autoimmune Encephalitis • Molecular mimicry, Abs bind to physiologic receptors; can be from underlying tumor (ovarian teratoma) • Seizures, movement disorders, psychiatric symptoms, catatonia • Often mistaken for suspected poisoning • LP/CSF: Send anti-NMDA receptor antibodies • Treatment: • Tumor resection if present, immunotherapy, steroids • Earlier detection/treatment = better outcomes

  25. Inborn Errors of Metabolism • Group of genetic disorders of metabolic/enzymatic pathways • Deficient end product or accumulation of toxic substrates, i.e. ammonia • Nonspecific Sx, ALOC/AMS, seizures, strokes, hematologic, hypotonia • Colonic microflora converts amino acids + urea to ammonia; liver converts back to urea (Urea Cycle) • Dysfunction can lead to hyperammonia Treatment • NPO • D10 @1.5 maintenance • Reverse Catabolic State • Na Phenylacetate or Benzoate • Treat Hyperammonemia • Alternative metabolic pathway • 0.25g/kg bolus over 2-4 hrs • Hemodialysis • For Refractory Hyperammonemia • Lactulose/Neomycin • For Hepatic Encephalopathy • Decreases colonic bacteria colonies

  26. Inborn Errors of Metabolism • Group of genetic disorders of metabolic/enzymatic pathways • Deficient end product or accumulation of toxic substrates, i.e. ammonia • Nonspecific Sx, ALOC/AMS, seizures, strokes, hematologic, hypotonia • Colonic microflora converts amino acids + urea to ammonia; liver converts back to urea (Urea Cycle) • Dysfunction can lead to hyperammonia Treatment • NPO • D10 @1.5 maintenance • Reverse Catabolic State • Na Phenylacetate or Benzoate • Treat Hyperammonemia • Alternative metabolic pathway • 0.25g/kg bolus over 2-4 hrs • Hemodialysis • For Refractory Hyperammonemia • Lactulose/Neomycin • For Hepatic Encephalopathy • Decreases colonic bacteria colonies

  27. Inborn Errors of Metabolism • Group of genetic disorders of metabolic/enzymatic pathways • Deficient end product or accumulation of toxic substrates, i.e. ammonia • Nonspecific Sx, ALOC/AMS, seizures, strokes, hematologic, hypotonia • Colonic microflora converts amino acids + urea to ammonia; liver converts back to urea (Urea Cycle) • Dysfunction can lead to hyperammonia Treatment • NPO • D10 @1.5 maintenance • Reverse Catabolic State • Na Phenylacetate or Benzoate • Treat Hyperammonemia • Alternative metabolic pathway • 0.25g/kg bolus over 2-4 hrs • Hemodialysis • For Refractory Hyperammonemia • Lactulose/Neomycin • For Hepatic Encephalopathy • Decreases colonic bacteria colonies

  28. Quiz

  29. Abdominal Intussusception • Triad – abdominal pain, palpable sausage mass, currant jelly stool • Intermittent abdominal pain with flexion of extremities; interval of no pain • Lethargy late finding with worsening bowel ischemia • Case reports of lethargy as only presenting symptom

  30. Abdominal Intussusception • Triad – abdominal pain, palpable sausage mass, currant jelly stool • Intermittent abdominal pain with flexion of extremities; interval of no pain • Lethargy late finding with worsening bowel ischemia • Case reports of lethargy as only presenting symptom

  31. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US Standard AMS labs, imaging (CT Head) +/- Empiric Antibiotics (If LP, perform w/in 2 hours of Abx)

  32. PedsAltered Mental Status Brief Focused Tox Exam • Mental Status • Skin • Eyes • Mucosal Membranes • Muscle Tone Basics • A • B • C • IV, O2, Monitor • FS • EKG • CXR • Blood Gas • +/- US Standard AMS labs, imaging (CT Head) +/- Empiric Antibiotics (If LP, perform w/in 2 hours of Abx)

  33. Quiz Review • Dose of Atropine • 0.02mg/kg • Dose of PGE1 / Side Effects • 0.1mcg/kg/min • Hypotension, Bradycardia, Apnea, Flushing • Dose for Activated Charcoal • 0.5-1g/kg <20kg • Typical Ssx for Anti-NMDA-R antagonist • Seizures, psychiatric/behavioral changes, movement disorders, AMS • Intussusception causes • Meckels diverticulum, tumors, HSP, Peyer patches

  34. Self-Reflect

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