Alterations in Consciousness

I’m Altered and ICan’t get Up

100

progressive deterioration in academic performance, withdrawal, depression and social isolation in the setting of malar rash

What is Systemic Lupus Erythematosis? Remember Clinical Features (4 of 11) Malar Rash on cheeks butterfly rash that spares nasolabial folds Discoid Rash-erythematosus rash with keratotic scaling Photosensitivity-skin rash as unusual reaction to sunlight Oral ulcers-ulcerations to mouth or nasal area painless Non erosive arthritis-two or more painful swollen joints Serosistis-pericarditis or pleuritis Persistent proteinuria Neurologic disorder-seizure or psychosis Hematologic Disorder Immunologic Disorder Positive ANA

200

profound impairment of consciousness without loss of body tone, lasting about 10 seconds

What is Absence Seizures? Median age of onset 6 y/o Short frequent episodes of impaired consciousness lasting 10 seconds Hyperventilation noted to trigger 90% of episodes Ictal signs noted include-staring, rapid eye movement and automatisms Rare for patients to have other seizure types

300

Haitian infant with increasing episodes of vomiting, poor oral intake and jerking motions noted of limbs for a few minutes on a daily basis. Mom describes eye look downwards at baseline.

What is hydrocephalus? Approximately 18000 shunts placed a year up to 40% fail in first year Half of patient will have malfunction in 1st 10 years 90% of shunt infections are diagnosed within 6 months of initial shunt placement or revision

400

Mom came home from evening shift on MLK day found teenager at home on sofa complaining of headache and now has progressive confusion, nausea and lethargy.

What is Carbon Monoxide Poisoning? Causes-smoke inhalation, malfunctioning appliances, exhaust fumes, methylene chloride CO reduces ability of hemoglobin to carry and release oxygen, binds to myoglobin reducing ability to move Remember benign symptoms-headache, nausea and fatigue, syncope. Labs shows metabolic acidosis

500

Extreme headache, vomiting then seizure-33% percent of patients with this presentation

What is AVM? Most common presenting symptoms are seizures can occur prior to rupture, headache and focal neurologic deficit. Intracranial hemorrhage most common in children compared to adults Diagnosis CT or MRI Angiography gold standard after treatment planning, follow-up and prognosis Risk factors for asymptomatic AVM’s to rupture-younger age, lesion size and location deep venous

I did not Mean to but I did

100

Toddler who presents with episodes of crying then cyanosis followed by unconsciousness

What is Breath Holding Spells? Misnomer spells are involuntarily Typical event frightening, startling, painful or upsetting to a child Skin can become pale or cyanotic Severe spells- can lead to loss of consciousness, myoclonic jerk, incontinence or stiffnesdrowsiness Palid spells result from vagally mediated cardiac inhibitory pathway Cyanotic spells more complex involving hyperventilatory-Valsalva pathway Most spells before 2nd birthday peal at 18 montsh, resolve mostly by 6 year 20-30% have a family history Management-Consider ordering Hgb, EKG if warranted, 50% in one study responded to iron therapy, severe refractory case-pacemaker

200

Anxiety, agiration delirium, restlessness and disorientation and hyperthermia in teenager who just started a new medication a few hours ago

What is Serotonin Syndrome? Symptoms-hyperthermia, agitation, dilated pupils, tremor, muscle rigidity, dry mucus membranes, flushed skin and diaphoreis Mental status changes include anxiety, diaphoresis, restlessness and disorientation Hunter Toxicty Criteria Decision Rules-spontaneous clonus, inducible clonus plus agitation or diaphoresis, tremor plus hyperreflexia, hypertonia plus temp>38 plus inducible or ocular clonus Tx-Benzodiazepens, discontinue Sertonin, sertonin antagonist

300

body builder teenager with increasing bizarre and agressive behavior

What is Steroid Induced Psychosis? Most common in doses greater than 20mg/day of prednisone 10% do not respond to reduction in steroids and need neuroleptics Hypoalbumnemia in the setting of SLE may induce psychosis Can be associated with mania, depression and a lesser extent panic disorder

400

5 y/o found in garage by parent found confused stating "I just wanted some of that sweet drink" and complaining of blurry vision.

What is Toxic Alcohol (Methanol or ethylene glycol)? Ingestion of 1g/kg can be lethal Lactate can be elevated due to misinterpretation of lactate vs glycolate or just mild elevations in serum lactate Urine for oxlate crystals (ethylene glycol) but late finding Calculate osmolar gap=2Na+Glu/18+Bun/2.8 Treatment Bicarbonate for acidosis and Fomepizole

500

Hypertensive and Tachycardic teenager with vomiting, dizziness and headache from herb found in cornfield

What is Jimson Weed? Anticholinergic poison-medications-atropine, amitryptiline, doxyalamine, scopolamine Red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter and full as a flask Treatment benzodiazepenes for agitation and delirium, physostigmine

What did I take

100

Used by 4% of world population (maybe even you) between ages 15-64 ingestants report brighter colors and more vivid music

Marijuana Comes from Canabis sativa, most important part THC in highest concentration in buds, fine powder is call hashish, Smoked (pipe, bomb, cigarettes) but effective orally User describes state of dreamy intoxication

200

Teenager complaing of vivid or distorted colors, euphoria, blending of senses

What is Hallucinogen-LSD? DXM, mescaline Bad trip-Dysphoira, fear and agitation Causes symptoms similar to serotonin syndrome increases serotonin Manage with calm supportive environment, benzodiazepenes for agitation, neuroleptic for psychotic features

300

Airline Traveler found a baggage claim with tachycardia, hypertension, agitation and acute onset of psychosis severe abdominal pain out of proportion to exam

What is Sympathomimetic? or What is a body packer? Intoxicated patient-restless, hypervigilant, agitated, anxious, paranoid delusional with frequent visual hallucination, dehyration,mydriasis Serious intoxcation patients note SI, or aggresive behavior Club drug as MDMA Hyperthermia tx with neuromuscolar blockade-dantrolene Seizures-benzodizepens or treat hyponatremia Hypertension with vasodialator

400

Toddler grabbing at the air, agitated, hypertensive, unsteady gait and dilated pupils

What is Anticholinergic? Diphenhydramine has sodium blockade effects along with anticholinergic effects Due to sodium blockade can cause prolonged QRS case report in (PEC 2011) noted this

500

Can lead to agitated delirium and psychotic features lasting for days to even weeks. Recently introduced into the US in 2010

What is Bath Salts? Similar to sympathomimetic but with hallucinogen effect profound delirium and psychotic features synthetic cathione Complications from Chronic abuse Rhabdomyolysis Valvular Heart Disease Cardiomyopathy Acute Tubular Necrosis Dysrhythmia Stroke Misleading labels

Miscellaneous Alterations

100

Teenage girl last seen combing her hair in the bathroom found down by parents

What is Syncope? Reflex/Neurally mediated Vasovagal, Situational (micturition, defecation, post exercise) atypical Cardiac Syncope Othostatic Hypotension Exertional Synope more concerning than post exertional syncope

200

Fever is not always present although often an infectious process treatment includes emergent LP and broad spectrum antibiotics

What is Encephalitis? Dx by MRI after negative serology May present with emotional lability, stupor, ataxia, hemiparesis Diagnostic testing can lead to etiology such as neutropenia and erhlichiosis, eosinophillia and trichinella or hyponatreimi rickettsiall CSF note pleocytosis, slightly elevated or normal protein Brain MRI maybe normal or note swelling or edema Clinical, Clinical, Clinical Diagnosis Empicic Treatment with Acyclovir

300

Infant male brought in by young first time mother who is recent immigrant to the US patient is altered with eye deviation and tachycardia

What is Hyponatremic Seizures? Causes of Hyponatremia: Congestive heart Failure, Water intoxication, Vomiting/Diarrhea, CF, Diuretics, Renal Losses, Burns/heat stroke Liver Disease, Nephrotic Syndrome, Renal Failure, SIADH Treatment-5ml/kg of 3%normal saline for serum sodium below 120mmol/L Rapid correction beyond bolus of NS can lead to pontine myelinolysis

400

hallmark of this syndrome is polymorphic ventricular tachycardia and 2/3 of patients present with syncope

What is Long QT Syndrome? Causes-Congenital, Acquired numerous meds Recurrent episodes of syncope then spontaneous return of consciousnes but can degnerate into ventricular fibrillation To induce ECG changes in suspected patients increasing sympathetic activity may trigger Admission for those who are symptomatic Normal ECG but highly concerning histories warrant halter monitor

500

Young girl complaining of worsening lethargy and headache over the past week along with blurry vision. Patient has ALL s/p induction of chemotherapy a week ago.

What is Posterior Reversible Encephalopathy Syndrome? Linked to immunosuppression and hypertension PE may note upgoing Babinski and brisk reflexes Treatment is symptomatic Antiepileptics Antihypertensives Can restart chemotherapy after symptoms resolve MRI images show symmetrical cerebral edema in posterior hemisphere temporal parietal Most patients recover in 2 weeks

Body Wacked Out

100

Young girl with AGE for a week, now lethargic with fruity odor to breath of note parents mention that over the last month she has had night time enuresis

What is Diabetic Ketoacidosis? Testing for serum beta-hydroxybutarate may be more accurate since that accounts for 75% of ketones Increase suspicion due to severe candida diaper rash or toddler with vaginal yeast infection Complications- Cerebral Edema Venous Thrombosis associated with femoral catheter placement Pancreatic enzyme replacement Cardiac arrhythmia Aspiration

200

19% of children present with lethargy or somnolence in addition to bloody stool

What is Intussusception? Painful episodes last 15-20 minutes One study noted presence of air in cecum on 2 views abdominal films had high sensitivity for excluding intussusception (PEC 2012, Sep 28 (9)855-8) Perforation after air or contrast reduction is 1% thus air is preferred Perforation occurs more commonly in under 6 months, evidence of SBO and symptomatic for 3 days

300

Depression and poor school performance with elevated liver enzymes.

What is Wilson's Disease? Consider in patients with hepatic, neurologic and psychiatric concerns Most common psychiatric concerns include depression,incongrous behavior and irritability Neurologic Manifestations Dysarthria Dystonia Essential Tremor Cognitive impairment Commonly seen in Pediatric patients with autoimmune hepatitis AST to ALT ratio >2

400

somnolence, inability to maintain normal body temperature and poor feeding in 3 day old newborn mom reports milk is just coming in over last day.

What is Urea Cycle Defects? Typical presentation-24-48 hours after birth after protein load-present with lethargy, vomiting, also central hyperventilation, posturing due to cerebral edema Atypical presentation after newborn period, chronic vomiting, developmental delay, sleep disorders, patients typically prefer vegetarian diet due to headache with protein load

500

Can present as newborn with lethargy and poor feeding or Asthmatic with alterations in mental status after multiple asthma exacerbations or caused by meningococcemia

What is adrenal insufficiency? Primary manifestations-hypotension, shock, hyponatremia and hyperkalemia and altered level of consiousness Generally precipiatated by mineralcorticoid deficiency Males often present as newborns to ED girls discovered in nursery due to genitalia