Altered Consciousness in Pediatrics: AEIOUTIPS, MOVESTUPID
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TOC Will Appear Here

Altered Level of Consciousness: Evidence-Based Management in the Emergency Department (Pharmacology CME)

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
    1. Toxicologic Etiologies
    2. Traumatic Etiologies
    3. Neurologic Etiologies
      1. Seizures
      2. Encephalopathy
      3. Ruptured Aneurysm Or Arteriovenous Malformation
      4. Stroke
      5. Cerebrospinal Fluid Shunt Malfunction
      6. Central Nervous System Vasculitis
      7. Infectious Causes
    4. Cardiac Etiologies
      1. Syncope
      2. Posterior Reversible Encephalopathy Syndrome
      3. Pericardial Tamponade
      4. Other Cardiac Etiologies
    5. Pulmonary Etiologies
    6. Endocrinologic Etiologies
      1. Hypoglycemia
      2. Diabetic Ketoacidosis
      3. Hyperglycemic Hyperosmolar State
      4. Hashimoto Encephalopathy
    7. Gastroenterological Etiologies
    8. Renal, Genetic, And Metabolic Etiologies
    9. Hematologic/Oncologic Etiologies
    10. Infectious Etiologies
      1. Meningitis
      2. Encephalitis And Encephalopathy
      3. Intracranial Abscess
      4. Tick-Borne Diseases
      5. Sepsis
    11. Environmental, Autoimmune, And Psychiatric Etiologies
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Initial Management
    2. History
    3. Physical Examination
  9. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
  10. Treatment
    1. General Treatment Strategies
    2. Condition-Specific Treatment
      1. Electrolyte Abnormalities
      2. Ingestion Or Exposure
      3. Fever
      4. Elevated Intracranial Pressure
      5. Seizure
      6. Neurologic Conditions
      7. Diabetic Ketoacidosis/Hyperglycemic Hyperosmolar State
      8. Hypertensive Encephalopathy
      9. Inborn Errors Of Metabolism
  11. Special Populations
  12. Controversies And Cutting Edge
  13. Disposition
  14. Summary
  15. Risk Management Pitfalls In Patients With Altered Level Of Consciousness
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway For Managing The Patient With Altered Level Of Consciousness In The Emergency Department
  19. Tables
    1. Table 1. Mnemonic For Differential Diagnosis Of Altered Level Of Consciousness
    2. Table 2. Differential Diagnosis Of Altered Level Of Consciousness
    3. Table 3. Toxidromes Resulting In Altered Levels Of Consciousness
  20. References

Abstract

A child who presents to the emergency department with an altered level of consciousness can be clinically unstable and can pose a great diagnostic challenge. The emergency clinician must quickly develop a wide differential of possible etiologies in order to administer potentially life-saving medications or interventions. The history, physical examination, and appropriate diagnostic tests can aid greatly in rapidly narrowing the differential diagnosis. Once initial stabilization, workup, and first-line interventions are completed, most patients who present with unresolved or unidentified altered level of consciousness should be admitted for further evaluation and close monitoring. This issue provides a review of the etiologies of altered level of consciousness as well as guidance for the management and disposition of patients with this condition.

Case Presentations

A 7-year-old previously healthy girl presents to the ED with fever, neck pain, and increased sleepiness since the previous day. The patient’s mother reports that she has had a nonproductive cough for the past 2 days, with associated nasal congestion and runny nose. She also notes that the girl has had a decreased appetite since the previous day, a temperature of 38.5ºC, neck pain, and has been lethargic. The patient’s mother does not report a rash, and the remainder of the review of systems is negative. On examination, the patient is found to be sleepy and slowly arousable to commands. The girl's pupils are equal, 4 mm, and react briskly to light. She winces with extension of her knees and has reflex flexion of her hips and knees upon passive neck flexion. As you discuss the likely diagnosis with the girl's mother, you start to think about the management of this patient: What laboratory studies should be sent? Which medications should be administered? Are imaging studies indicated at this time?

A 14-year-old previously healthy adolescent boy presents to the ED after being found by his parents in his room, unconscious. Hours prior to being found, the patient was reportedly with his friends at the movies and was in his usual state of health. His parents deny any fever, nausea, vomiting, or known trauma. The physical examination is notable for a well-developed male who is lethargic and makes only incomprehensible sounds. His physical examination is otherwise normal. What are the likely etiologies for this patient’s altered mental status? What are some interventions that can be initiated to prevent morbidity?

A 9-year-old girl with propionic acidemia presents to the ED with 3 days of nonbloody, nonbilious emesis, and 1 day of lethargy and increased work of breathing. She has not been able to eat anything as a result of the vomiting. Her parents report that she woke up this morning looking very tired and sleepy, which prompted them to bring her to the hospital. The parents deny any fever, diarrhea, or preceding upper respiratory symptoms. The physical examination is notable for disorientation to person, place, and date. She has dry mucous membranes and a capillary refill time of 2 seconds. Her vital signs are as follows: temperature, 37ºC; heart rate, 150 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 80/40 mm Hg. You know that you’ll need to hydrate this patient, but which intravenous fluids should you use? At what rate should the intravenous fluids run? What other interventions will be needed?

Introduction

The term altered level of consciousness (ALOC) can be used to describe a spectrum of disorders that includes clouding of consciousness, confusion, lethargy, obtundation, stupor, or coma.1,2 In young children, ALOC may manifest as fussiness or irritability. Due to the varying degrees of altered consciousness, it is important for the emergency clinician to be familiar with the various terms that can be used to describe a patient’s clinical status, and to recognize that there is much similarity among them.

  • Clouding of consciousness can include a very mild form of ALOC in which there is inattention, decreased alertness, and reduced wakefulness.
  • Confusion involves a state of disorientation, along with bewilderment and difficulty following commands.
  • Lethargy describes severe drowsiness, though the patient can still be aroused with moderate stimuli.
  • Obtundation is similar to lethargy but with slowed responses to stimulation and decreased periods of time spent in wakefulness.
  • Stupor refers to a mental state when the patient can only be aroused by repeated and vigorous stimuli (such as pain).
  • Coma is a persistent state of unresponsiveness despite attempts of arousal.1,2

ALOC can be induced by traumatic or nontraumatic mechanisms. In a British epidemiological study completed in 2001, the incidence of nontraumatic coma in children aged < 16 years was reported to be 30.8 per 100,000 per year, with a noted increased incidence in children aged < 1 year (160 per 100,000 per year).In other hospital-based studies, nontraumatic coma was noted to be more common in children aged < 6 years than in older children.4

Etiologies for ALOC can be numerous, but a broad differential can be reviewed quickly with the aid of mnemonics such as MOVESTUPID, which is adapted from adult emergency medicine practice. (See Table 1.) Other commonly used mnemonics include AEIOU TIPS (alcohol/acidosis, epilepsy, insulin, overdose, uremia, trauma, infection, psychosis, stroke) or DPT OPV HIB MMR (dehydration, poisoning, trauma; occult trauma, postictal/ postanoxia, ventriculoperitoneal shunt; hypoxia/ hyperthermia, intussusception, brain masses; meningitis/encephalitis, metabolic, Reye syndrome/rare causes).Of these etiologies, the most common cause of nontraumatic coma is an infectious etiology.3,6

Table 1 Mnemonic For Differential Diagnosis Of Altered Level Of Consciousness

This month’s issue of Pediatric Emergency Medicine Practice will review a broad differential diagnosis for pediatric patients who present to the emergency department (ED) with ALOC, as well as present the initial workup and interventions to stabilize such patients.

Critical Appraisal Of The Literature

An online literature search was performed using the PubMed and Ovid MEDLINE® databases with the search terms altered level of consciousnessacute loss of consciousnessaltered mental status, and coma. For literature searches using the search terms altered mental status and coma, fields were limited to the age group between 0 and 18 years of age and articles written in the English language. A total of 381 articles were reviewed. In addition, individual literature searches were performed for each of the differential diagnoses listed in Table 2 and reviewed for relevance to ALOC or altered mental status. The Cochrane Database of Systematic Reviews was searched using the key terms altered level of consciousnessacute loss of consciousness, and altered mental status, but no reviews were found; using the key term coma, 31 reviews were identified.

Risk Management Pitfalls In Patients With Altered Level Of Consciousness

  1. “The patient was drinking alcohol while driving and got into a car accident. His altered mental status must be from his intoxication.”
    Although alcohol intoxication may contribute to the patient’s ALOC, it is important to rule out any other concomitant etiologies for the patient’s ALOC, including, but not limited to, intracranial injury due to the motor vehicle crash.
     
  2. “I thought that this was her neurological baseline.”
    In special populations that include developmentally delayed patients, it is imperative to ask the caretaker(s) what the patient’s neurological baseline is in order to correctly assess and evaluate any changes in levels of consciousness.
     
  3. “The patient was still seizing after the first 4 doses of lorazepam and 2 doses of fosphenytoin, so we proceeded to place the patient in a phenobarbital coma without further investigation.”
    The differential for a patient presenting with seizures includes electrolyte derangements—including hyponatremia and hypoglycemia—as potential etiologies. The emergency clinician should not only prepare to administer benzodiazepines and other antiepileptic agents, but also to correct any potential electrolyte derangements that may be the cause of seizure. Other causes for seizures can include toxic exposures or ingestions that may need to be considered as well.
     
  4. “Even though her GCS score was 7, I needed a CT scan emergently, so I sent her for the scan without further stabilizing her.” Unless the patient’s mental status is quickly improving and returning to neurological baseline, patients with a persistent GCS score of ≤ 8 should be intubated in order to protect their airway, given their unstable neurological status.
     
  5. “I could not obtain cerebrospinal fluid from the lumbar puncture, so I held off on antibiotics.”
    If infectious causes are highly suspected in a patient with ALOC, the inability to obtain CSF should not cause unnecessary delay to administration of antibiotic therapy.
     
  6. “I knew the diagnosis, so I did not do a complete neurological examination.”
    Once the ABCs of a patient with ALOC are stabilized, details of the neurological examination can provide critical information. For example, anisocoria can reflect signs of impending brain herniation and papilledema can serve as a sign indicating increased intracranial pressure secondary to mass effect on the brain.
     
  7. “I thought the patient’s irregular breathing was due to his mental status.”
    Emergency clinicians should not focus solely on the patient’s neurological presentation, as this could result in failure to piece together other presenting signs and symptoms to ascertain the correct diagnosis. For example, respiratory changes can be important clinical findings to indicate Kussmaul breathing, as seen in DKA, or erratic or irregular breathing, as seen in Cushing triad.
     
  8. “The patient initially presented with hypoglycemia, and a dextrose bolus was given. Once the hypoglycemia was addressed, I did not think to start dextrose-containing intravenous fluids.”
    Patients who present with hypoglycemia should not only be given a dextrose bolus, but should also have their glucose level rechecked and monitored closely. In addition, if hypoglycemia persists, dextrose-containing fluids should be started at 1.5 times maintenance rate to ensure a steady glucose infusion rate until the etiology for hypoglycemia can be ascertained. Plasma glucose checks should be completed frequently until a stable level > 70 mg/dL is attained more than once.32
     
  9. “The patient was hyponatremic and altered. I subsequently gave a 20 mL/kg normal saline bolus and started the patient on normal saline intravenous fluids at 1.5 times maintenance rate.”
    Correcting hyponatremia should be done slowly, due to the risk of central pontine myelinolysis. The recommended rate of correction is such that the patient’s serum sodium levels should not rise more than 12 to 15 mEq/L (12-15 mmol/L) over a 24-hour period.
     
  10. “He initially came into the ED looking intoxicated. I did not think that there would have been any issues with cervical spine instability.”
    In all patients presenting with ALOC, trauma must be considered in the differential. If trauma is highly suspected as the etiology for the patient’s ALOC, care must be taken to ensure proper cervical spine precautions. Similarly, it is important to fully undress the patient with ALOC to avoid missing skin findings, signs of trauma, or other cutaneous clues that may otherwise be hidden underneath clothing.

Tables

Table 1. Mnemonic For Differential Diagnosis Of Altered Level Of Consciousness

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

  1. * Avner JR. Altered states of consciousness. Pediatr Rev. 2006;27(9):331-338. (Review article)
  2. Tindall SC. Level of Consciousness. In: Walker HK, Hall WD, Hurst JW, eds. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston: Butterworth Publishers, a division of Reed Publishing; 1990. (Textbook)
  3. Wong CP, Forsyth RJ, Kelly TP, et al. Incidence, aetiology, and outcome of non-traumatic coma: a population based study. Arch Dis Child. 2001;84(3):193-199. (Prospective, epidemiologic, population-based study; 283 episodes representing 278 children)
  4. Seshia SS, Bingham WT, Kirkham FJ, et al. Nontraumatic coma in children and adolescents: diagnosis and management. Neurol Clin. 2011;29(4):1007-1043. (Review article)
  5. Schunk JE. The pediatric patient with altered level of consciousness: remember your “immunizations.” J Emerg Nurs. 1992;18(5):419-421. (Review article)
  6. Ahmed S, Ejaz K, Shamim MS, et al. Non-traumatic coma in paediatric patients: etiology and predictors of outcome. J Pak Med Assoc. 2011;61(7):671-675. (Cross-sectional study; 100 patients)
  7. Hoffman R, Wang V, Scarfone RJ, eds. Fleisher and Ludwig’s 5-Minute Pediatric Emergency Medicine Consult. 1st ed. Philadelphia: Lippincott, Williams & Wilkins; 2012. (Textbook)
  8. Zeman A. Consciousness. Brain. 2001;124(Pt 7):1263-1289. (Review article)
  9. Calello DP, Fine JS, Marcus SM, et al. 2012 pediatric fatality review of the National Poison Database System. Clin Toxicol (Phila). 2014;52(2):93-95. (Database review; 50 patients)
  10. Mowry JB, Spyker DA, Brooks DE, et al. 2014 annual report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 32nd annual report. Clin Toxicol (Phila). 2015;53(10):962-1147. (Annual report)
  11. Kurt F, Bektas O, Kalkan G, et al. Does age affect presenting symptoms in children with carbon monoxide poisoning? Pediatr Emerg Care. 2013;29(8):916-921. (Retrospective study; 261 patients)
  12. Mendoza JA, Hampson NB. Epidemiology of severe carbon monoxide poisoning in children. Undersea Hyperb Med. 2006;33(6):439-446. (Epidemiologic study; 250 consecutive children)
  13. Bailey JE, Campagna E, Dart RC. The underrecognized toll of prescription opioid abuse on young children. Ann Emerg Med. 2009;53(4):419-424. (Descriptive; 9179 pediatric exposures)
  14. Tonisson M, Tillmann V, Kuudeberg A, et al. Acute alcohol intoxication characteristics in children. Alcohol Alcohol. 2013;48(4):390-395. (Prospective study; 256 children)
  15. Lamminpaa A. Acute alcohol intoxication among children and adolescents. Eur J Pediatr. 1994;153(12):868-872. (Review article)
  16. Rayar P, Ratnapalan S. Pediatric ingestions of house hold products containing ethanol: a review. Clin Pediatr (Phila). 2013;52(3):203-209. (Literature review)
  17. Sutton TL, Foster RL, Liner SR. Acute methanol ingestion. Pediatr Emerg Care. 2002;18(5):360-363. (Case report)
  18. Slaughter RJ, Mason RW, Beasley DM, et al. Isopropanol poisoning. Clin Toxicol (Phila). 2014;52(5):470-478. (Review)
  19. Barry JD. Diagnosis and management of the poisoned child. Pediatr Ann. 2005;34(12):937-946. (Review article)
  20. Malone DC, Abarca J, Hansten PD, et al. Identification of serious drug-drug interactions: results of the partnership to prevent drug-drug interactions. J Am Pharm Assoc (2003). 2004;44(2):142-151. (Cross-sectional; 54 drug-drug interactions)
  21. American Psychiatric Association DSM-5 Task Force. Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. Washington, D.C.: American Psychiatric Association; 2013. (Classification and diagnostic manual)
  22. Croarkin PE, Emslie GJ, Mayes TL. Neuroleptic malignant syndrome associated with atypical antipsychotics in pediatric patients: a review of published cases. J Clin Psychiatry. 2008;69(7):1157-1165. (Literature review)
  23. Ty EB, Rothner AD. Neuroleptic malignant syndrome in children and adolescents. J Child Neurol. 2001;16(3):157-163. (Review article)
  24. Neuhut R, Lindenmayer JP, Silva R. Neuroleptic malignant syndrome in children and adolescents on atypical antipsychotic medication: a review. J Child Adolesc Psychopharmacol. 2009;19(4):415-422. (Literature review)
  25. Wright RO, Lewander WJ, Woolf AD. Methemoglobinemia: etiology, pharmacology, and clinical management. Ann Emerg Med. 1999;34(5):646-656. (Review article)
  26. Appelboam A, Oades PJ. Coma due to cannabis toxicity in an infant. Eur J Emerg Med. 2006;13(3):177-179. (Case report)
  27. Holstege CP, Borek HA. Toxidromes. Crit Care Clin. 2012;28(4):479-498. (Review article)
  28. Quayle KS, Powell EC, Mahajan P, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014;371(20):1945-1947. (Letter to the editor, secondary analysis; 43,399 patients)
  29. Atabaki SM. Pediatric head injury. Pediatr Rev. 2007;28(6):215-224. (Review article)
  30. * Schunk JE, Schutzman SA. Pediatric head injury. Pediatr Rev. 2012;33(9):398-410. (Review article)
  31. Holsti M, Kadish HA, Sill BL, et al. Pediatric closed head injuries treated in an observation unit. Pediatr Emerg Care. 2005;21(10):639-644. (Retrospective cohort review; 285 patients)
  32. * Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Wolters Kluwer/Lippincott Williams & Wilkins Health; 2010. (Textbook)
  33. Hinds T, Shalaby-Rana E, Jackson AM, et al. Aspects of abuse: abusive head trauma. Curr Probl Pediatr Adolesc Health Care. 2015;45(3):71-79. (Review article)
  34. Ewing-Cobbs L, Kramer L, Prasad M, et al. Neuroimaging, physical, and developmental findings after inflicted and noninflicted traumatic brain injury in young children. Pediatrics. 1998;102(2 Pt 1):300-307. (Prospective, longitudinal study; 40 children)
  35. Benson PJ, Klein EJ. New-onset absence status epilepsy presenting as altered mental status in a pediatric patient. Ann Emerg Med. 2001;37(4):402-405. (Case report)
  36. Amin OS. A prolonged altered mental status: is it absence status epilepticus? BMJ Case Rep. 2013. (Case report)
  37. Luders H, Amina S, Bailey C, et al. Proposal: different types of alteration and loss of consciousness in epilepsy. Epilepsia. 2014;55(8):1140-1144. (Consensus opinion article)
  38. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808. (Classification criteria)
  39. Wong ST, Fong D. Ruptured brain arteriovenous malformations in children: correlation of clinical outcome with admission parameters. Pediatr Neurosurg. 2010;46(6):417-426. (Retrospective review; 40 patients)
  40. Bristol RE, Albuquerque FC, Spetzler RF, et al. Surgical management of arteriovenous malformations in children. J Neurosurg. 2006;105(2 Suppl):88-93. (Retrospective review; 82 patients)
  41. Krishnamurthi RV, deVeber G, Feigin VL, et al. Stroke prevalence, mortality and disability-adjusted life years in children and youth aged 0-19 years: data from the Globaland Regional Burden of Stroke 2013. Neuroepidemiology. 2015;45(3):177-189. (Epidemiologic study; 97,792 cases)
  42. Lynch JK, Hirtz DG, DeVeber G, et al. Report of the National Institute of Neurological Disorders and Stroke workshop on perinatal and childhood stroke. Pediatrics. 2002;109(1):116- 123. (Workshop report)
  43. Delsing BJ, Catsman-Berrevoets CE, Appel IM. Early prognostic indicators of outcome in ischemic childhood stroke. Pediatr Neurol. 2001;24(4):283-289. (Retrospective review; 31 children)
  44. Hedlund GL. Cerebral sinovenous thrombosis in pediatric practice. Pediatr Radiol. 2013;43(2):173-188. (Review article)
  45. Wong JM, Ziewacz JE, Ho AL, et al. Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery. Neurosurg Focus. 2012;33(5):E13. (Literature review)
  46. Riva-Cambrin J, Kestle JR, Holubkov R, et al. Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg Pediatr. 2015:1-9. (Multicenter prospective cohort study; 1036 children)
  47. McGirt MJ, Leveque JC, Wellons JC 3rd, et al. Cerebrospinal fluid shunt survival and etiology of failures: a seven-year institutional experience. Pediatr Neurosurg. 2002;36(5):248- 255. (Retrospective review; 353 patients)
  48. Kim TY, Stewart G, Voth M, et al. Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department. Pediatr Emerg Care. 2006;22(1):28-34. (Retrospective review; 352 patients)
  49. * Van Mater H. Pediatric inflammatory brain diseases: a diagnostic approach. Curr Opin Rheumatol. 2014;26(5):553-561. (Review article)
  50. Benseler S, Pohl D. Childhood central nervous system vasculitis. Handb Clin Neurol. 2013;112:1065-1078. (Textbook)
  51. Alper G. Acute disseminated encephalomyelitis. J Child Neurol. 2012;27(11):1408-1425. (Review article)
  52. Johnsrude CL. Current approach to pediatric syncope. Pediatr Cardiol. 2000;21(6):522-531. (Review article)
  53. Anderson JB, Czosek RJ, Cnota J, et al. Pediatric syncope: National Hospital Ambulatory Medical Care survey results. J Emerg Med. 2012;43(4):575-583. (Retrospective observational study; 627,489 ED visits from 2003-2007)
  54. Chandar J, Zilleruelo G. Hypertensive crisis in children. Pediatr Nephrol. 2012;27(5):741-751. (Review article)
  55. Yang WC, Wu HP. Clinical analysis of hypertension in children admitted to the emergency department. Pediatr Neonatol. 2010;51(1):44-51. (Retrospective review; 99 patients)
  56. Endo A, Fuchigami T, Hasegawa M, et al. Posterior reversible encephalopathy syndrome in childhood: report of four cases and review of the literature. Pediatr Emerg Care. 2012;28(2):153-157. (Report of 4 cases and literature review)
  57. Raj S, Overby P, Erdfarb A, et al. Posterior reversible encephalopathy syndrome: incidence and associated factors in a pediatric critical care population. Pediatr Neurol. 2013;49(5):335-339. (Retrospective cohort study; 10 patients)
  58. Hinchey J, Chaves C, Appignani B, et al. A reversible posterior leukoencephalopathy syndrome. N Engl J Med. 1996;334(8):494-500. (Retrospective review; 15 patients)
  59. Milner D, Losek JD, Schiff J, et al. Pediatric pericardial tamponade presenting as altered mental status. Pediatr Emerg Care. 2003;19(1):35-37. (Case report)
  60. Lane JR, Ben-Shachar G. Myocardial infarction in healthy adolescents. Pediatrics. 2007;120(4):e938-e943. (Retrospective review; 9 patients)
  61. Goldstein B, Shannon DC, Todres ID. Supercarbia in children: clinical course and outcome. Crit Care Med. 1990;18(2):166-168. (Retrospective review; 5 patients)
  62. de Groot EP. Breathing abnormalities in children with breathlessness. Paediatr Respir Rev. 2011;12(1):83-87. (Review article)
  63. Piña-Garza JE. Fenichel's Clinical Pediatric Neurology: A Signs and Symptoms Approach. 7th ed. Elsevier Science Health Science Division; 2013. (Textbook)
  64. Falk JL, Escowitz HE. Submersion injuries in children and adults. Semin Respir Crit Care Med. 2002;23(1):47-55. (Review article)
  65. * Casaletto JJ. Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness. Emerg Med Clin North Am. 2010;28(3):633-662. (Review article)
  66. Pershad J, Monroe K, Atchison J. Childhood hypoglycemia in an urban emergency department: epidemiology and a diagnostic approach to the problem. Pediatr Emerg Care. 1998;14(4):268-271. (Retrospective review; 31 patients)
  67. Losek JD. Hypoglycemia and the ABC’S (sugar) of pediatric resuscitation. Ann Emerg Med. 2000;35(1):43-46. (Cross-sectional study; 9 patients)
  68. Cooke DW, Plotnick L. Management of diabetic ketoacidosis in children and adolescents. Pediatr Rev. 2008;29(12):431-435. (Review article)
  69. Neu A, Willasch A, Ehehalt S, et al. Ketoacidosis at onset of type 1 diabetes mellitus in children--frequency and clinical presentation. Pediatr Diabetes. 2003;4(2):77-81. (Retrospective review; 2121 children)
  70. Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. N Engl J Med. 2001;344(4):264-269. (Retrospective, multicenter)
  71. Rosenbloom AL. Hyperglycemic hyperosmolar state: an emerging pediatric problem. J Pediatr. 2010;156(2):180-184. (Review article)
  72. Erol I, Saygi S, Alehan F. Hashimoto’s encephalopathy in children and adolescents. Pediatr Neurol. 2011;45(6):420-422. (Case report)
  73. Mamoudjy N, Korff C, Maurey H, et al. Hashimoto’s encephalopathy: identification and long-term outcome in children. Eur J Paediatr Neurol. 2013;17(3):280-287. (Retrospective observational study; 42 children)
  74. Vasconcellos E, Pina-Garza JE, Fakhoury T, et al. Pediatric manifestations of Hashimoto’s encephalopathy. Pediatr Neurol. 1999;20(5):394-398. (Report of 2 cases and literature review)
  75. Weihmiller SN, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Pediatrics. Vol 2011;127(2):e296-e303. (Prospective, observational, cohort study; 310 patients)
  76. Shaoul R, Gazit A, Weller B, et al. Neurological manifestations of an acute abdomen in children. Pediatr Emerg Care. 2005;21(9):594-597. (Report of 2 cases)
  77. Godbole A, Concannon P, Glasson M. Intussusception presenting as profound lethargy. J Paediatr Child Health. 2000;36(4):392-394. (Case report)
  78. Pumberger W, Dinhobl I, Dremsek P. Altered consciousness and lethargy from compromised intestinal blood flow in children. Am J Emerg Med. 2004;22(4):307-309. (Retrospective review; 13 patients)
  79. Farrar HC, Chande VT, Fitzpatrick DF, et al. Hyponatremia as the cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors. Ann Emerg Med. 1995;26(1):42-48. (Retrospective review; 47 patients)
  80. Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S829-S861. (Guidelines)
  81. Uribarri J, Oh MS, Carroll HJ. D-lactic acidosis. A review of clinical presentation, biochemical features, and pathophysiologic mechanisms. Medicine (Baltimore). 1998;77(2):73-82. (Case report and literature review)
  82. Powers KS. Dehydration: isonatremic, hyponatremic, and hypernatremic recognition and management. Pediatr Rev. 2015;36(7):274-283. (Review article)
  83. Hahn JS, Havens PL, Higgins JJ, et al. Neurological complications of hemolytic-uremic syndrome. J Child Neurol. 1989;4(2):108-113. (Retrospective review; 78 children)
  84. Bauer A, Loos S, Wehrmann C, et al. Neurological involvement in children with E. coli O104:H4-induced hemolytic uremic syndrome. Pediatr Nephrol. 2014;29(9):1607-1615. (Retrospective review; 50 patients)
  85. Squires RH Jr, Shneider BL, Bucuvalas J, et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr. 2006;148(5):652-658. (Prospective multicenter case study; 348 children)
  86. Kamboj M. Clinical approach to the diagnoses of inborn errors of metabolism. Pediatr Clin North Am. 2008;55(5):1113- 1127. (Review article)
  87. Levy PA. Inborn errors of metabolism: part 1: overview. Pediatr Rev. 2009;30(4):131-137. (Review article)
  88. Ficicioglu C, An Haack K. Failure to thrive: when to suspect inborn errors of metabolism. Pediatrics. 2009;124(3):972-979. (Review article)
  89. * Galal NM, Fouad HM, Saied A, et al. Hyperammonemia in the pediatric emergency care setting. Pediatr Emerg Care. 2010;26(12):888-891. (Observational study; 50 cases)
  90. Lanphear J, Sarnaik S. Presenting symptoms of pediatric brain tumors diagnosed in the emergency department. Pediatr Emerg Care. 2014;30(2):77-80. (Retrospective review; 87 patients)
  91. Wilne S, Collier J, Kennedy C, et al. Presentation of childhood CNS tumours: a systematic review and meta-analysis. Lancet Oncol. 2007;8(8):685-695. (Literature review)
  92. Combs D, Rice SA, Kopp LM. Incidence of delirium in children with cancer. Pediatr Blood Cancer. 2014;61(11):2094-2095. (Retrospective review; 7 patients)
  93. Antunes NL. Mental status changes in children with systemic cancer. Pediatr Neurol. 2002;27(1):39-42. (Review of 546 consultations)
  94. Lowe EJ, Pui CH, Hancock ML, et al. Early complications in children with acute lymphoblastic leukemia presenting with hyperleukocytosis. Pediatr Blood Cancer. 2005;45(1):10-15. (Retrospective review; 178 children)
  95. * Kliegman, RM, Stanton BMD, St. Geme J III, et al. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier Saunders; 2011. (Textbook)
  96. McCavit TL. Sickle cell disease. Pediatr Rev. 2012;33(5):195- 204. (Review article)
  97. DeBaun MR, Kirkham FJ. Central nervous system complications and management in sickle cell disease. Blood. 2016;127(7):829-838. (Review article)
  98. Brook I. Brain abscess in children: microbiology and management. J Child Neurol. 1995;10(4):283-288. (Review article)
  99. Gelabert-Gonzalez M, Aran-Echabe E. Management of brain abscess. Turk Neurosurg. 2013;23(5):692. (Retrospective review; 28 patients)
  100. Sennaroglu L, Sozeri B. Otogenic brain abscess: review of 41 cases. Otolaryngol Head Neck Surg. 2000;123(6):751-755. (Retrospective review; 41 cases)
  101. Sun J. Intracranial complications of chronic otitis media. Eur Arch Otorhinolaryngol. 2014;271(11):2923-2926. (Retrospective review; 17 patients)
  102. Mace SE. Central nervous system infections as a cause of an altered mental status? What is the pathogen growing in your central nervous system? Emerg Med Clin North Am. 2010;28(3):535-570. (Review article)
  103. Mann K, Jackson MA. Meningitis. Pediatr Rev.. 2008;29(12):417-429. (Review article)
  104. Lewis P, Glaser CA. Encephalitis. Pediatr Rev. 2005;26(10):353-363. (Review article)
  105. Lim M, Hacohen Y, Vincent A. Autoimmune encephalopathies. Pediatr Clin North Am. 2015;62(3):667-685. (Review article)
  106. DuBray K, Anglemyer A, LaBeaud AD, et al. Epidemiology, outcomes and predictors of recovery in childhood encephalitis: a hospital-based study. Pediatr Infect Dis J. 2013;32(8):839- 844. (Retrospective cohort study; 190 patients)
  107. Bonfield CM, Sharma J, Dobson S. Pediatric intracranial abscesses. J Infect. 2015;71 Suppl 1:S42-S46. (Review article)
  108. Sood SK. Lyme disease in children. Infect Dis Clin North Am. 2015;29(2):281-294. (Review article)
  109. Avery RA, Frank G, Glutting JJ, et al. Prediction of Lyme meningitis in children from a Lyme disease-endemic region: a logistic-regression model using history, physical, and laboratory findings. Pediatrics. 2006;117(1):e1-e7. (Clinical prediction model; 175 children)
  110. Garro AC, Rutman M, Simonsen K, et al. Prospective validation of a clinical prediction model for Lyme meningitis in children. Pediatrics. 2009;123(5):e829-e834. (Prospective validation study; 50 children)
  111. Glaser C, Christie L, Bloch KC. Rickettsial and ehrlichial infections. Handb Clin Neurol. 2010;96:143-158. (Textbook)
  112. Buckingham SC, Marshall GS, Schutze GE, et al. Clinical and laboratory features, hospital course, and outcome of Rocky Mountain spotted fever in children. J Pediatr. 2007;150(2):180-184. (Retrospective review; 92 patients)
  113. Shah RG, Sood SK. Clinical approach to known and emerging tick-borne infections other than Lyme disease. Curr Opin Pediatr. 2013;25(3):407-418. (Review article)
  114. Gofton TE, Young GB. Sepsis-associated encephalopathy. Nat Rev Neurol. 2012;8(10):557-566. (Review article)
  115. Bergeron MF. Reducing sports heat illness risk. Pediatr Rev. 2013;34(6):270-279. (Review article)
  116. Centers for Disease Control and Prevention. Hypothermia-related deaths--United States, 2003-2004. MMWR Morb Mortal Wkly Rep. 2005;54(7):173-175. (Epidemiological report)
  117. Anyaegbu E, Goodman M, Ahn SY, et al. Acute intermittent porphyria: a diagnostic challenge. J Child Neurol. 2012;27(7):917-921. (Case report)
  118. Puy H, Gouya L, Deybach JC. Porphyrias. Lancet. 2010;375(9718):924-937. (Review article)
  119. Punja M, Pomerleau AC, Devlin JJ, et al. Anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis: an etiology worth considering in the differential diagnosis of delirium. Clin Toxicol (Phila). 2013;51(8):794-797. (Report of 2 cases)
  120. DeSena AD, Greenberg BM, Graves D. Three phenotypes of anti-N-methyl-D-aspartate receptor antibody encephalitis in children: prevalence of symptoms and prognosis. Pediatr Neurol. 2014;51(4):542-549. (Report of 8 cases and literature review)
  121. Reilly C, Menlove L, Fenton V, et al. Psychogenic nonepileptic seizures in children: a review. Epilepsia. 2013;54(10):1715- 1724. (Seminal article)
  122. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84. (Seminal article)
  123. Reilly PL, Simpson DA, Sprod R, et al. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988;4(1):30-33. (Literature review)
  124. James HE, Anas NG, Perkin RM, eds. Brain Insults in Infants and Children: Pathophysiology and Management. New York: Grune & Stratton; 1985. (Textbook)
  125. Chabali R. Diagnostic use of anion and osmolal gaps in pediatric emergency medicine. Pediatr Emerg Care. 1997;13(3):204- 210. (Review article; 2 case reports)
  126. Yock-Corrales A, Barnett P. The role of imaging studies for evaluation of stroke in children. Pediatr Emerg Care. 2011;27(10):966-974. (Review article)
  127. Hunter JV, Morriss MC. Neuroimaging of central nervous system infections. Semin Pediatr Infect Dis. 2003;14(2):140-164. (Review article)
  128. Elbers J, Wainwright MS, Amlie-Lefond C. The Pediatric Stroke Code: early management of the child with stroke. J Pediatr. 2015;167(1):19-24.e1-4. (Review article)
  129. Barnette AR, Horbar JD, Soll RF, et al. Neuroimaging in the evaluation of neonatal encephalopathy. Pediatrics. 2014;133(6):e1508-e1517. (International multicenter database study; 4171 infants enrolled)
  130. Boyle TP, Paldino MJ, Kimia AA, et al. Comparison of rapid cranial MRI to CT for ventricular shunt malfunction. Pediatrics. 2014;134(1):e47-e54. (Retrospective cohort study; 698 ED visits for 286 unique patients)
  131. Kim I, Torrey SB, Milla SS, et al. Benefits of brain magnetic resonance imaging over computed tomography in children requiring emergency evaluation of ventriculoperitoneal shunt malfunction: reducing lifetime attributable risk of cancer. Pediatr Emerg Care. 2015;31(4):239-242. (Retrospective case series; 365 patients)
  132. Guse SE, Neuman MI, O’Brien M, et al. Implementing a guideline to improve management of syncope in the emergency department. Pediatrics. 2014;134(5):e1413-e1421. (Quasi-experimental study; 349 children)
  133. Lapus RM. Activated charcoal for pediatric poisonings: the universal antidote? Curr Opin Pediatr. 2007;19(2):216-222. (Review article)
  134. Chyka PA, Seger D, Krenzelok EP, et al. Position paper: Single-dose activated charcoal. Clin Toxicol (Phila). 2005;43(2):61- 87. (Position paper)
  135. American Academy of Clinical Toxicology; European Association of Poison Centres and Clinical Toxicologists. Position statement and practice guidelines on the use of multi-dose activated charcoal in the treatment of acute poisoning. J Toxicol Clin Toxicol. 1999;37(6):731-751. (Position statement)
  136. American Academy of Pediatrics Committee on Drugs: naloxone dosage and route of administration for infants and children: addendum to emergency drug doses for infants and children. Pediatrics. 1990;86(3):484-485. (Addendum)
  137. Kreshak AA, Tomaszewski CA, Clark RF, et al. Flumazenil administration in poisoned pediatric patients. Pediatr Emerg Care. 2012;28(5):448-450. (Retrospective cohort study; 83 patients)
  138. Lexi-Comp Online™. Pediatric & Neonatal Lexi-Drugs Online™, Hudson, Ohio: Lexi-Comp, Inc. November 22, 2015. (Reference manual)
  139. Dhossche DM, Wachtel LE. Catatonia is hidden in plain sight among different pediatric disorders: a review article. Pediatr Neurol. 2010;43(5):307-315. (Review article)
  140. Watts W, Edge JA. How can cerebral edema during treatment of diabetic ketoacidosis be avoided? Pediatr Diabetes. 2014;15(4):271-276. (Review article)
  141. Zeitler P, Haqq A, Rosenbloom A, et al. Hyperglycemic hyperosmolar syndrome in children: pathophysiological considerations and suggested guidelines for treatment. J Pediatr. 2011;158(1):9-14, 14.e11-2. (Guidelines)
  142. Adelman RD, Coppo R, Dillon MJ. The emergency management of severe hypertension. Pediatr Nephrol. 2000;14(5):422- 427. (Review article)
  143. Baracco R, Mattoo TK. Pediatric hypertensive emergencies. Curr Hypertens Rep. 2014;16(8):456. (Review article)
  144. Bergmann KR, McCabe J, Smith TR, et al. Late-onset ornithine transcarbamylase deficiency: treatment and outcome of hyperammonemic crisis. Pediatrics. 2014;133(4):e1072-e1076. (Case report)
  145. Claudius I, Fluharty C, Boles R. The emergency department approach to newborn and childhood metabolic crisis. Emerg Med Clin North Am. 2005;23(3):843-883, x. (Review article)
  146. Summar M. Current strategies for the management of neonatal urea cycle disorders. J Pediatr. 2001;138(1 Suppl):S30-S39. (Review article)
  147. Batshaw ML, MacArthur RB, Tuchman M. Alternative pathway therapy for urea cycle disorders: twenty years later. J Pediatr. 2001;138(1 Suppl):S46-S54. (Review article)
  148. Cochran JB, Losek JD. Acute liver failure in children. Pediatr Emerg Care. 2007;23(2):129-135. (Review article)
  149. Jackson BF, Porcher FK, Zapton DT, et al. Cerebral sinovenous thrombosis in children: diagnosis and treatment. Pediatr Emerg Care. 2011;27(9):874-880. (Review article)
  150. Wasay M, Dai AI, Ansari M, et al. Cerebral venous sinus thrombosis in children: a multicenter cohort from the United States. J Child Neurol. 2008;23(1):26-31. (Retrospective study; 70 children)
  151. Xiao HY, Wang YX, Xu TD, et al. Evaluation and treatment of altered mental status patients in the emergency department: life in the fast lane. World J Emerg Med. 2012;3(4):270-277. (Prospective observational cohort study; 1934 patients)
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