Pediatric altered mental status

Abstract

Dr. Nathan Mick: Today’s case is that of a 6-month-old female presenting with decreased responsiveness. The patient was well until that morning when she was difficult to arouse from sleep. The patient’s mother noted that during the past week the child had begun to sleep through the night without waking. At 7:00 that morning when she went in to awaken the child and couldn’t, she assumed the child was “tired” and allowed her to remain sleeping. One hour later, she again had difficulty waking her daughter and called her pediatrician who urged her to have her daughter evaluated in the Emergency Department (ED). The mother reported that her daughter was an only child with no recent sick contacts and that the house contained no prescription medications. The child’s past medical history was notable for a normal term labor and vaginal delivery. There had been no significant illnesses. She was breast fed until 3 months of age and then transitioned to formula. The patient was cared for by her maternal grandmother during the daytime as her parents both worked outside the home. She had met normal developmental milestones to date. She was on no prescription medications, had no allergies, and was up to date on all immunizations including the pneumococcal vaccine. The patient lived with her mother and father, who had been married 5 years. Dr. Eric Nadel: Are there any questions about the initial history? Dr. Jessica Peters: Was there any history of trauma? Dr. Nathan Mick: The mother denied any history of trauma in the preceding week. The child was able to crawl but not walk and there were no stairs or other “high risk” areas in the home. The child’s initial vital signs were: pulse 140 beats/ minute, respiratory rate 30 breaths/minute, oxygen saturation 99%, temperature 37°C, and blood pressure 96/50 mm Hg. The physical examination revealed a well-developed, well-nourished 6-month-old lying quietly on a gurney. The skin examination revealed no petechiae or ecchymoses. The head and neck examinations revealed no signs of otitis media, trauma, nuchal rigidity, or pharyngitis. The pupils were normal, round and reactive. There was no respiratory distress and breath sounds were clear. The heart and abdominal examinations were normal. The child was listless with open eyes and very little movement of the extremities. She did not respond negatively to separation from her mother and did not respond to venipuncture and vascular access. Dr. Eric Nadel: Are there any questions regarding the physical examination? Dr. Todd Thomsen: Perhaps the most ominous finding on examination is the lack of response to “stimulation” via needle stick. Was this child protecting her airway? Dr. Nathan Mick: The child was handling her secretions without difficulty and was ventilating normally with a normal oxygen saturation, so immediate airway