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902 SECTION 12: Pediatrics TABLE 139-8 Commonly Used Medications for Migraine Prophylaxis in Children Class Medication Dosage Calcium channel blocker Flunarizine 10 milligrams/d Nimodipine 10 milligrams/d (<40 kg), 16 milligrams/d (40–50 kg), 20 milligrams/d (>50 kg) β-Blocker Propranolol 10 milligrams PO twice a day up to 20 milligrams 3 times a day as tolerated for age <14 y; 20 milligrams twice a day to 120 milligrams twice a day as tolerated for age >14 y Nitrogen alkaloid Papaverine 5 milligrams/kg/d in divided doses twice a day Tricyclic antidepressant Amitriptyline 10 milligrams PO at bedtime to maximum of 50 milligrams PO at bedtime for age <12 y and 100 milligrams PO at bedtime for age >12 y Antiepileptic
day to 120 milligrams twice a day as tolerated for age >14 y Nitrogen alkaloid Papaverine 5 milligrams/kg/d in divided doses twice a day Tricyclic antidepressant Amitriptyline 10 milligrams PO at bedtime to maximum of 50 milligrams PO at bedtime for age <12 y and 100 milligrams PO at bedtime for age >12 y Antiepileptic Topiramate 50 milligrams/d titrated to 200 milligrams/d in divided doses 3 times a day Divalproex sodium 125–250 milligrams PO at bedtime to twice a day for age >10 y Nutraceuticals Riboflavin (B 2) Coenzyme Q10 Melatonin 400 milligrams/d 100–150 milligrams/d 6–12 milligrams before bed Antihistamine Cyproheptadine 4 milligrams PO at bedtime to maximum of 12 milligrams at bedtime for age >6 y therapy for migraine (cluster headache may be treated the same way) and tension-type headache. THIRD-LINE THERAPY Subanesthetic dose propofol has been evaluated in the ED in a randomized controlled trial in children with encouraging results. 75 This study found that propofol, given as a 0.25 milligram/kg IV push every 5 minutes to a maximum of five doses, achieved similar pain reduction as standard therapy with dopamine antagonists and NSAIDs, with significantly fewer 24-hour rebound headaches and a nonsignificant shorter median length of stay. However, depending on institutional policies for propofol administration, monitoring or personnel requirements may make its use provider intensive in some settings, limiting its practicality. Dihydroergotamine is effective in the inpatient setting, but no studies exist on ED treatment. 76 Although effective in adults, data are lacking with regard to the utility of dexamethasone for prevention of headache recurrence following abortive therapy. 77-80 Antipsychotics such as dro peridol and haloperidol are not recommended for children due to high rates of side effects. Additional therapies specific to cluster headache include 100% oxygen via non-rebreather mask for 20 minutes at onset of headache; lidocaine 20 milligrams intranasal to the ipsilateral nostril, and prednisone 1 to 2 milligrams/kg for 10 days with a subsequent 7-day taper to terminate prolonged clustering of headaches. PROPHYLACTIC TREATMENT Children with chronic headaches that disrupt activities of daily liv ing or school performance may benefit from prophylactic treatment. While initiation of daily prophylaxis is typically beyond the scope of ED management, Table 139-8 lists medications used for the prevention of migraines. Few of these medications are supported by quality evidence, and a recent multicenter randomized, double-blind, placebo-controlled trial comparing topiramate, amitriptyline, and placebo found no differ ence in headache frequency and higher rates of side effects in the medi cation arms. 81 The decision to start prophylaxis should be made by the primary care physician or pediatric neurologist, in consultation with the child and the family, and should include a careful weighing of the risks and benefits of daily medication. NONPHARMACOLOGIC TREATMENT For tension-type headaches and migraines, a range of nonpharmacologic therapy including biofeedback, relaxation techniques, and cognitive behavioral therapy can be effective. 82,83 In general, 8 to 10 sessions are necessary to teach these techniques in the outpatient setting. Although acupuncture has been used to treat chronic migraine headaches in both children and adults, several randomized controlled studies failed to show benefit over placebo. DISPOSITION AND FOLLOW-UP Admit children with emergent, life-threatening causes of headache to the hospital for definitive treatment and pain control. Consider admis sion for children with primary headaches with intractable pain despite first- and second-line treatment.
lled studies failed to show benefit over placebo. DISPOSITION AND FOLLOW-UP Admit children with emergent, life-threatening causes of headache to the hospital for definitive treatment and pain control. Consider admis sion for children with primary headaches with intractable pain despite first- and second-line treatment. Patients with recurrent headaches who are successfully treated and discharged from the ED should be encouraged to keep a daily headache diary to document the frequency of headaches, impact on daily activities, and potential triggers. Healthy lifestyle changes may help reduce headache frequency and can be recalled using the SMART acronym: adequate sleep, regular meals and activity, relaxation techniques, and trigger avoidance. Remind them that first-line treatments are most effective when taken early in the course of headache. For those with frequent headaches, a trial of daily nutraceuticals (Table 139-8) may be reasonable and safe. Ensure follow-up with a primary care provider or headache specialist. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Altered Mental Status in Children Melisa S. Tanverdi Sarah A. Mellion INTRODUCTION Altered mental status in children is characterized by the failure to respond to verbal or physical stimulation in a manner appropriate to the child’s developmental level. The ED incidence of altered mental status in children varies widely depending on the type of institution reporting, the patient population served, and the specific definition of altered mental status used. 1,2 Children with altered mental status require simultaneous stabilization, diagnosis, and treatment. The objectives of treatment are to sustain life and prevent irreversible CNS damage. Once the patient is resuscitated, the goal is to determine the cause and stop disease progression. PATHOPHYSIOLOGY Arousal is mediated by the neural pathways of the ascending reticular activating system that project from the brainstem to the hypothalamus, thalamus, and cerebral cortices. The ascending reticular activating system regulates wakefulness in response to the environment, as well as homeostasis, cardiovascular, and respiratory functions. Altered mental status occurs through dysfunction of the ascending reticular activating system, an insult to bilateral cerebral cortices, or global depression of the central nervous system. 3,4 There are many factors that can cause dysfunction in the ascending reticular activating system and cerebral hemispheres, including inadequate substrate for metabolic demand, insufficient blood CHAPTER Tintinalli_Sec12_p0669-0996.indd 902 8/2/19 7:56 PM
l cortices, or global depression of the central nervous system. 3,4 There are many factors that can cause dysfunction in the ascending reticular activating system and cerebral hemispheres, including inadequate substrate for metabolic demand, insufficient blood CHAPTER Tintinalli_Sec12_p0669-0996.indd 902 8/2/19 7:56 PM CHAPTER 140: Altered Mental Status in Children 903 Children”), the most simplified and functional scale in an emergency setting is the AVPU scale ( Table 140-2). The Glasgow Coma Scale lacks good interobserver reliability and reproducibility and does not accurately predict outcomes in individual patients. 8 The AVPU score has been validated and is currently recommended by the Pediatric Advanced Life Support guidelines. 9 The A, V , P , and U values correspond to Glasgow Coma Scale scores of 15, 13, 8, and 3, respectively.10 After obtaining a comprehensive history and performing a complete physical examination, including thorough neurologic examination, anticipate and carefully observe for improvement or deterioration.11 DIAGNOSIS Once the child is stabilized, the history and physical should suggest either a medical disorder or structural lesion. The mnemonic AEIOU TIPS (alcohol, encephalopathy, insulin, opiates, uremia, trauma, infection, poisoning, and seizure) is a useful tool for organizing the diagnostic possibilities of altered mental status in children (Table 140-3). If a metabolic cause is suspected, obtain serum electrolyte levels, renal and hepatic function studies, serum ammonia, CBC, and coagulation studies (see Chapter 146, “Metabolic Emergencies in Infants and Chil dren”). If the history or examination suggests a toxic ingestion, obtain serum levels of suspected agents and a urine toxicology screen. Consider trial of an antidote, if available. Obtain arterial blood gas analysis, CBC, and pulse oximetry in cases of trauma, respiratory distress, or suspected acid-base imbalance. Obtain a 12-lead ECG and provide continuous cardiac monitoring if there are pathologic auscultatory findings, rhythm disturbance, or suspected toxin exposure. For serious bacterial infec tion, obtain blood and urine cultures. Correct shock, hypotension, and hypoxia before attempting lumbar puncture (see Chapter 119, “Fever and Serious Bacterial Illness in Infants and Children”). The clinical scenario directs imaging. Immobilize the cervical spine and radiograph the cervical spine if spine injury is suspected or in the case of multiple system trauma. If an intracranial lesion is suspected or if there are focal neurologic signs, obtain a noncontrast CT scan of the head. If vascular injury is a possibility, consider CT angiography of the head and/or neck. A chest radiograph confirms or clarifies examination findings and documents endotracheal tube placement. Abdominal radiographs are indicated to assess for acute ingestion of radiopaque material. Abdominal US may be useful to screen for cases of intussusception (see Chapter 133, “ Acute Abdominal Pain in Infants and Children”). Other studies that may be useful in specific cases are serum osmo lality, blood alcohol level, thyroid function tests, blood lead level, and skeletal survey for suspected abuse. Electroencephalogram will evaluate for nonconvulsive status epilepticus. TREATMENT Treatment principles are outlined in Table 140-4. Begin with airway, breathing, and circulation, and administer 100% oxygen until adequate oxygenation is confirmed. For suspected increased intracranial pres sure, elevate the head of the bed to 30 degrees. Establish an IV and give normal saline to restore and/or maintain perfusion. Obtain a stat pointof-care glucose and treat hypoglycemia. If the history or the exam suggests opiate toxicity, give naloxone. 6 For suspected meningitis, give antibiotics and/or acyclovir.
pres sure, elevate the head of the bed to 30 degrees. Establish an IV and give normal saline to restore and/or maintain perfusion. Obtain a stat pointof-care glucose and treat hypoglycemia. If the history or the exam suggests opiate toxicity, give naloxone. 6 For suspected meningitis, give antibiotics and/or acyclovir. DISPOSITION AND FOLLOW-UP Once the patient is stabilized, the child should be observed until his or her mental status improves. The patient’s clinical condition and specific disorder dictate whether further management can occur on the inpatient TABLE 140-1 Important Historical Elements for Evaluating Altered Mental Status in Children Prodromal events Recent illnesses or infectious exposures History of recent trauma Risk factors Medications in the home Social environment Vaccinations Family history Developmental milestones Associated symptoms Constitutional Neurologic Cardiac Musculoskeletal Dermatologic Fever, weight loss Vomiting, diarrhea, abdominal pain Headache, gait changes, seizure activity, weakness Palpitations Head tilt Rash TABLE 140-2 AVPU Score A = Awake V = Responds to verbal stimuli P = Responds to pain U = Unresponsive flow, presence of toxins or metabolic waste products, or alterations of body temperature.4 Typical causes of bilateral cortical impairment are toxic and metabolic states that deprive the brain of normal substrates. There are multiple pathologic conditions that affect awareness and arousal; etiologies can initially be described as traumatic or nontrau matic. Nontraumatic causes can be further divided into structural and functional lesions. Structural lesions can be categorized as supratentorial or subtentorial. Signs and symptoms of supratentorial lesions include focal motor abnormalities, which are often present from the onset of the altered level of consciousness. Subtentorial lesions lead to reticular activating system dysfunction, in which prompt loss of consciousness is common. Cranial nerve abnormalities are frequent, and abnormal respiratory patterns are seen. Functional etiologies include infectious/inflamma tory, metabolic/nutritional/toxic, and neurologic/psychiatric disorders. Depressed consciousness is typically seen before motor signs become depressed, and when present, motor deficits are typically symmetric. CLINICAL FEATURES AND APPROACH The spectrum of alteration of mental status ranges from confusion or delirium (disorders in perception) to lethargy, stupor, and coma (states of decreased awareness). A lethargic child has decreased awareness of self and the environment. Patients may be aroused from an appar ent deep sleep, but they immediately relapse into a state of minimal responsiveness. A stuporous child has decreased eye contact, decreased motor activity, and unintelligible vocalization. Stuporous patients can be aroused with vigorous noxious stimulation. Comatose patients are unresponsive and cannot be aroused by verbal or physical stimulation, such as phlebotomy, arterial catheterization, or lumbar puncture. Rapidly assess and support the airway, ventilation, and circulation. When the patient is stabilized, take a methodical and comprehensive history (Table 140-1). Ask about the prodromal events before the change in consciousness as well as recent illnesses or infectious exposures, and determine the likelihood of trauma, abuse, or ingestion. Inquire about antecedent fever, headache, head tilt, abdominal pain, vomiting, diar rhea, gait disturbance, seizures, drug ingestion, palpitations, weakness, hematuria, weight loss, and rash. For infants and young children, review developmental milestones. The medical, immunization, and family histories are important in children of all ages.
t fever, headache, head tilt, abdominal pain, vomiting, diar rhea, gait disturbance, seizures, drug ingestion, palpitations, weakness, hematuria, weight loss, and rash. For infants and young children, review developmental milestones. The medical, immunization, and family histories are important in children of all ages. Be alert for any inappropriate responses, inconsistencies, or delays in seeking care that may arouse suspicion for child abuse (see Chapter 150, “Child Abuse and Neglect”). 6,7 Proceed with a general examination only after respiratory, cardiac, and cerebral stabilization. The objectives of the examination are to identify occult infection, trauma, toxicity, or metabolic disease. The neurologic examination should document the child’s response to sensory input, motor activity, pupillary reactivity, oculovestibular reflexes, and respiratory pattern. Although several coma scales have been published, such as the Modified Pediatric Glasgow Coma Scale (see Chapter 110, “Pediatric Trauma, ” and Chapter 111, “Minor Head Injury and Concussion in Tintinalli_Sec12_p0669-0996.indd 903 8/2/19 7:56 PM