Pediatric Altered Mental Status - Dr. MacNeill

There is a lot to think about... but don't forget the sugar!!

BASICS

• Brain needs glucose, O2, electrolytes, nl electrical activity, no structural defects, no inflammation or infection

• Transient vsPersistent Change in MS
  

1. Transient - usually benign, common, think electricity and perfusion
2. Persistent - dangerous, structural, metabolic, electrical
   

Seizure

• CT?
• Emergent CT - Less than 2 yrs, focality, abnl neuro exam, status, evidence of increased icp
• Infant sz hard to detect- behavioral arrest, hypomotor, pallor, cyanosis, repetitive movt
  

• Set the expectation -

1. Outpt EEG and MRI only if EEG supports the need or syndrome
2. Return to ED for sz in next 24hr, or last more than 5 min.
   
3. Send home with diastat.
   

Syncope

• Lifetime incidence  up to 40%,
• Plumbing issue - decreased Cardiac Output, decreased TPR. Reflex syncope is combo of both
  

• Sudden cardiac death - 50% with CV cause

1. HOCM - deep and narrow q waves in lateral leads, tall r waves in v1, high left ventricular voltage, syncope not always exertional, atypical CP, 1/2 family hx, Doppler echo for dx
2. Anomalous coronary arteries - 1/2 sx before death, syncope with exercise, nl EKG, ventric arrhythmia, dx by echo or CTA 
3. Long QT syndrome - stress syncope,exercise, bradycardia, 1/3 will have nl EKG, 10% of healthy people have long QT
   
4. Brugada - rbbb and downs sloping ST in V1-V3, vtach, fib, triggers for Dysrhythmia sleep and rest when Vagal tone is high, fever, check lytes
5. Arrhythmogenic RV Dysplasia - autosomal dominant, RV myocardium deposition with fibrofatty tissue, widened QRS
6. Catecholeminergic polymorphic VTACH - Rare, structurally normal, nl EKG, family hx
7. Myocarditis - recent febrile illness rash fatigue, PE nl, EKG ectopy, nl sinus tach, cardiac MRI
   

Red flags of syncope - exertional (not after the exertion), family hx, cp, palpitations, syncope, brought on by sudden loud noise, febrile illness, abrupt syncope, <10 years

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