Case 24

2-YEAR-OLD WITH ALTERED MENTAL STATUS -

Madelyn
Author: Harris Burstin, M.D., New York University School of Medicine
Summary of clinical scenario:
Madelyn is a two-year-old female who became acutely agitated and then difficult
to arouse at home. Her family lives with her great-aunt who is a diabetic and her
father found pills in an opened plastic container on the floor. On exam she is
agitated, mildly febrile, slightly hypotensive and tachycardic with dilated pupils.
She is hypoglycemic on presentation, consistent with anti-hyperglycemic
ingestion, but her mental status does not improve with IV glucose. EKG shows
signs of cardiotoxicity, confirming suspicion of additional tricyclic antidepressant
ingestion. Madelyn improves with administration of cathartic agent, activated
charcoal, serum alkalization, and sodium loading.
Key Findings from
History
No recent illness
No history of trauma
Abrupt onset of confusion and
agitation followed by excessive
somnolence
Key Findings from
Physical Exam
Agitation
Tachycardia
Hypotension
Dilated pupils
Hot, dry skin
Differential Diagnosis
Accidental ingestion of:
Tricyclic antidepressant
Selective serotonin reuptake inhibitor
Decongestant
Antihistimine
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Anti-hyperglycemic
Key findings from
Testing
Hypoglycemia
EKG: Irregularly irregular rhythm and
wide QRS
Final Diagnosis
Accidential nortriptyline and glipizide
ingestion
Case highlights: This case highlights the need to address the most immediate
and life-threatening issues first in the approach to an unresponsive child. In the
setting of an unknown ingestion, students review the classical clinical features and
how they may provide clues to the unknown ingested substance. The case
demonstrates evaluation and management of tricyclic antidepressant toxicity and
hypoglycemia, and discusses how to address home safety with families in the
aftermath of a toxic ingestion.
Key Teaching Points
Knowledge
Approach to the unresponsive child (or child with altered mental status):
Assess airway, breathing and circulation
Goal: Identify any life-threatening conditions and avoid further
deterioration
1.
Once patient is stable:
Gather more historical information
Perform a more detailed exam
Order appropriate tests
Consider life-threatening conditions:
External sources (like trauma or ingestion)
Internal sources (like infection, intussusception, seizures, or
metabolic disease)
2.
Skills
Physical exam:
Toxidromes (patterns of findings in toxic exposures)
Cholinergic (organophosphates):
Miosis and blurred vision
Increased gastric motility (nausea, vomiting, diarrhea)
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Excessive tearing, salivation, sweating, and urination
Bronchorrhea and bronchospasm
Muscle twitching and weakness
Bradycardia
Seizures and coma
Anticholinergic (diphenhydramine, tricyclic antidepressants):
Mydriasis (dilated pupils)
Decreased gastric motility (ileus)
Hot (fever), dry and flushed skin
Urinary retention
Tachycardia and hypertension
Delirium and seizures
Sedative-hypnotic (benzodiazepines, barbiturates):
Blurred vision (miosis or mydriasis)
Hypotension
Apnea and bradycardia
Hypothermia
Sedation, confusion, delirium, coma
Opioids (codeine, morphine, heroin):
Miosis (constricted pupils)
Respiratory depression
Bradycardia and hypotension
Hypothermia
Depressed mental status (sedation, confusion, coma)
Sympathomimetics (cocaine, amphetamines, pseudoephedrine, clonidine):
Mydriasis
Fever and diaphoresis
Tachycardia
Agitation and seizures
Others:
Iron: Severe abdominal symptoms followed by signs of shock
Beta-blocker: Bradycardia
Acetaminophen: Minimal initial symptoms (gastrointestinal symptoms not
uncommon), followed by symptoms of liver toxicity
Aspirin: Agitation and tachycardia; no mydriasis
Toxidrome Vitals Skin Pupils
Other
neuro-
logical
Abdo-
minal
exam
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findings
Cholinergic HR decr.
Dia-
phoretic
Con-
stricted
Seizures
Muscle
twitching
Hyper
active
Anti-
cholinergic
HR incr. Dry Dilated
Seizures
Delerium
Hypo
active
Sedative-
hypnotic
HR decr.
BP decr.
RR decr.

Sedation
Confusion
Delirium
Coman
Hypo
active
Opiod
HR decr.
BP decr.
RR decr.
hypo-
thermia

Con-
stricted
Hyper-
refelexia
Agitation
Seizures
Hypo
active
Sympatho-
mimetic
HR incr.
BP incr.
RR incr.
hyper-
thermia
Dia-
phoretic
Dilated
Hyper
active

Differential diagnosis
Ingestion of:
Tricyclic antidepressant (TCA):
Classic presentation: Agitation, cardiac manifestations (especially
hypotension), dilated pupils and dry, hot skin. Also unique cardiac
manifestations (including hypotension).
1.
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Ingestion of only one or two pills of nortriptyline can cause serious
symptoms in a two-year-old.
Peak effect seven or eight hours after ingestion.

Selective serotonin reuptake inhibitor (SSRI):
More commonly prescribed than tricyclic antidepressants, but there is
data that older adults tolerate TCAs better and they are more effective
for severe depression.
Significant overdose required to cause toxicity.
Serotonin syndrome: Profuse sweaty skin, agitation, fever, mental
status changes, diarrhea, myoclonus, hyperreflexia, ataxia, and
shivering.
2.
Decongestant: Overdose results in sympathomimetic toxidrome:
Tachycardia, hypertension, agitation, sweating, fever, mydriasis, and
seizures.

3.
Antihistamine: Anticholinergic effects, much like those in TCA ingestions.

4.
Anti-hyperglycemic:
Hypoglycemia at presentation in an unresponsive child (especially one
who lives with an individual with a history of diabetes) strongly
suggests an ingestion of an anti-hyperglycemic agent.
One 5 mg tablet of glipizide can cause significant hypoglycemia in a
two-year-old.
Peak toxicity is in two to three hours, but effect can last 24 hours.
5.
Studies
Glucose:
Many emergency departments will check a fingerstick blood glucose on
arrival of an unresponsive child.
In a patient with hypoglycemia it is critical to rapidly correct the
hypoglycemia and frequently reassess the serum glucose.
Complete blood count: Provides evidence against infection.
Electrolytes and blood gas:
Used to identify metabolic acidosis/anion gap. Both are characteristic of
aspirin/nonsteroidal anti-inflammatory (NSAID) toxicity.
Abnormal levels of calcium and magnesium could also affect cardiac
function.
EKG:
EKG is required since TCA toxicity can lead to serious dysrhythmias.Toxicology
screen (urine or blood):
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Although the results will not be immediately available, it is important to
obtain the sample early.
Will help confirm the working diagnosis
Acetaminophen level:
Acetaminophen toxicity initially presents with minimal symptoms.
Most common accidental ingestion.
CT scan of the head: Usually mandatory for a child with altered mental status
and agitation, but the danger of transport to radiology would need to be weighed
against its usefulnesswhen there is no historical nor clinical evidence for an
intracranial mass lesion or increased intracranial pressure.
Management
Hypoglycemia:
Critical to rapidly correct the hypoglycemia.
An IV bolus of dextrose 25% followed by maintenance fluids with
dextrose is recommended.
Blood glucose should be reassessed frequently.
Octreotide, a somatostatin analog, inhibits insulin release and may be
indicated as an antidote in dextrose-refractory sulfonylurea overdose.
Contact the poison control center:
An important early step in the management of an unknown ingestion
Poison control centers provide free 24-hour professional expertise about the
diagnosis and treatment of poisonings to anyone.
Toxin elimination:
Use of gastric decontamination is controversial.
Considerations should include:
Amount and timing of ingestion
Nature of ingested substance (e.g., binding characteristics,
caustics/corrosives)
Patient characteristics (e.g., mental status and airway security
Methods
Activated charcoal:
For ingestions not due to small molecules or heavy metals.
Contraindicated in a patient with loss of protective airway reflexes due
to aspiration risk. Elective intubation should be considered.
When anticholinergic agent (such as TCAs) has been ingested,
additional doses of activated charcoal may be indicated due to
decreased gastrointestinal motility.
Cathartic agent: A single dose may be given with the initial dose of
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charcoal.
Gastric lavage:
No demonstrated consistent clinical benefit, although one adult study
showed improved clinical outcomes within one hour of a tricyclic
ingestion.
Technically difficult to a pass a large enough tube in a two-year-old
child.
Syrup of ipecac: The American Academy of Pediatrics recommends that
syrup of ipecac not be used as first-line therapy for ingestions due to
potential side effects (risk of aspiration with altered mental status and
potential for serious cardiac side effects and seizures).
Hemodialysis and hemoperfusion: Method of decontamination, but not
indicated with TCA ingestion due to high level of protein-binding.
Urinary alkalinization: Specific method of decontamination for salicylate
intoxication.
TCA cardiotoxicity:The triad of cardiac effects (conduction delays, dysrhythmias,
and hypotension) requires immediate evaluation and treatment:
Continuous cardiac monitoring and serial EKGs: Required for a
minimum of six hours. (Most patients develop major clinical toxicity within
several hours of presentation.)

1.
Serum alkalization and sodium loading
Background: Serum pH affects protein binding of TCAs, and metabolic
acidosis can depress cardiac function.
Indicated for:
QRS > 100 msec
R wave in AVR > 3 mm
Wide-complex tachycardias
Fluid-refractory hypotension
Seizures
Dose: 1 mEq/kg hypertonic sodium bicarbonate bolus and every three
to five minutes thereafter until the QRS narrows and hypotension
improves.
Target: serum pH 7.507.55; close monitoring of blood gases is
required.
Duration: Because of drug redistribution from the tissues, need to
continue alkilization 1224 hours after EKG normalizes.
Lidocaine may be administered for life-threatening dysrhythmias.
2.
Hypotension: Along with volume expansion, serum alkalization, and
sodium loading are the mainstays of hypotensive therapy.
Beta-adrenergic agonists and dopamine are contraindicated.
Norepinephrine may be used in refractory situations (0.10.2 mcg/kg
/min).
3.
Seizures:
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Seizures due to TCA toxicity are generally brief.Benzodiazepines,
barbiturates, or propofol may be used in addition to alkalization for seizure
treatment. Phenytoin use is controversial and usually is not indicated due to
its potential for cardiac toxicity.
Home safety:
The best way to address home safety with families in the aftermath of an
accidental injury or ingestion depends on the familys emotional state.
Most effective approach in the emergency department might be to assess
immediate home safety, provide a mix of reassurance and limited guidance,
to be followed by later reinforcement in the context of primary care.
Many hospitals have policies requiring a formal social work consult in the
event of an accidental injury or ingestion.

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