AMS in children: Finding diagnostic clarity when the clinical presentation is murky
AMS in children: Finding diagnostic clarity when the clinical presentation is murky
By Stephan R. Paul, MD, Esq., Department of Pediatrics, Temple University School of Medicine, Philadelphia.
Editor's Note: As if communication with young children was not challenging enough, the child presenting with an altered mental status (AMS) is an exceptional opportunity for testing one's sleuthing ability. The reality is that we see far more adults with AMS than we do children. Consequently, we might be tempted for just a moment to doubt our abilities. But when we stop to think about it, the causes of AMS in children are not too different than those seen with adults, and emergency physicians have had lots of practice sorting through similar presentations. Nevertheless, one's ability to obtain an accurate history and to develop a practical list of differential diagnoses will be tested. Hence, it is incumbent upon physicians and nurses to be knowledgeable of those conditions causing children to present to the emergency department (ED) with an AMS. In this article, Dr. Paul reviews many of those conditions as well as reminds us of the potential medical-legal pitfalls that we may encounter. — Larry Mellick, MD, MS, FAAP, FACEP
Introduction
An alteration in mental status in a child presenting to the ED is an unusual, but potentially life-threatening event. Because of the wide range of differential diagnoses and the great potential for serious error, this remains an area of potential litigation for the emergency physician. Changes in mental status can present as impairment of attention, deficit of language and/or visual and special skills, and deterioration in cognition.1 Because of the challenges associated with pediatric mental status assessment, the evaluation of a change of mental status may be difficult.
A variety of conditions must be considered when searching for an etiology for a pediatric patient with a change in mental status (See Table 1.)1
| TABLE 1. Underlying Causes of Delirium |
|---|
 |
The workup of a child with an altered mental status may include the following laboratory and imaging studies: Routine blood chemistries, complete blood count, electrocardiogram, chest x-ray, measurement of blood gases or oxygen saturation, urinalysis, urine drug screen, heavy metal screening, antinuclear antibodies, serum ammonia level measurement, blood cultures, measurement of serum levels of medications, and computed tomography (CT) or magnetic resonance imaging (MRI) of the head. An electroencephalogram (EEG) may be indicated as seizures also may present as acute changes in mental status.2
Infection
Although there are few epidemiologic studies, pediatric patients appear to be at greater risk for delirium with fever regardless of the etiology, a presentation that raises the specter of a central nervous system (CNS) infection.3 (CNS Infections have been discussed in detail in a previous article.4)
Symptoms suggesting an acute CNS system infection—including a change in mental status — should be considered a medical emergency requiring rapid assessment and treatment.5 Although bacterial meningitis classically may present with acute onset of fever, headache, and meningismus, there are more subtle presentations of CNS infections, particularly in younger patients. Encephalitis may cause cognitive deficits, alterations of consciousness, and disorders of sensation, speech, or movement.6
Meningitis continues to cause severe morbidity and, in children, is a major source of medical malpractice cases involving pediatricians and ED physicians. Meningitis is defined as an inflammatory process of two meningeal membranes—the arachnoid and pia matter—surrounding the brain and the spinal cord. Inflammatory cells flow into the cerebrospinal fluid from the meninges, producing an increased white count that is the diagnostic hallmark of the disease. Changes in mental status occur when the inflammation of the meninges spreads to the adjacent brain parenchyma, and the child develops encephalitis. Another hallmark of meningitis is the increasing intracranial pressure, which can cause brain pathology through the reduction of cerebral perfusion, cerebral ischemia, and potential herniation.7,8 Sequelae from bacterial meningitis in young children are particularly severe despite major improvements in pediatric intensive care. Survivors have the risk for life-long neurological handicaps.
Case #1. Gartner v. Hemmer.9
A 5-month-old girl, Holly Gardner, presented to an ED with emesis, high fever, lethargy, and extreme irritability. She had vomited twice, had a fever of 103.5 oF, and was extraordinarily irritable with incessant crying. The emergency physician ordered a chest x-ray, urinalysis, blood count, and blood culture. The white blood cell count was 16.4 x 103/ mm3 with a significant bandemia. The results of the blood culture were pending upon discharge from the ED. The patient had a history of multiple episodes of otitis media, however, her ears were normal on physical examination. Acetaminophen was administered. Following a temperature reduction of two degrees, the patient was discharged home with a presumptive diagnosis of a viral illness. Her parents called the ED at least twice, complaining that the fever persisted and that she remained irritable. The parents were not instructed to return to the ED. The following morning, the parents made an appointment with their pediatrician who sent Miss Gardner back to the ED for a lumbar puncture that revealed bacterial meningitis. The child was impaired permanently from the alleged delay in diagnosis and treatment of meningitis.
In the trial court, the plaintiffs' infectious disease expert testified that the patient's initial presentation was consistent with a bacterial infection, and that the failure to treat with antibiotics was a proximate cause of the onset of meningitis and the subsequent neurologic damages. Originally, the jury found in favor of the defendants. But the plaintiffs appealed based on the preclusion of their infectious disease expert due to a successful motion that the infectious disease expert was not qualified to testify regarding the standard of care of an ED physician.
The appellate court reviewed the components of admissible testimony on the part of an expert. The appellate court acknowledged the limitations of the infectious disease expert, but held that his expertise was "beyond the knowledge of laypersons," and, as such, could assist the jury in its fact-finding role. The judgment was reversed, and the case remanded for a new trial.
Analysis
The medical consequences of a delay in diagnosis of meningitis or encephalitis provide one of the most common reasons for medical malpractice actions. Because a change in mental status is a common sign of meningitis or encephalitis, it is an important sign to consider in the general or pediatric ED. Long-term custodial care of neurologically impaired children makes these cases quite expensive when the ruling is in the favor of the plaintiffs. As discussed in a previous article in ED Legal Letter,10 McAbee recently reviewed malpractice cases involving meningitis in the pediatric population.11 A review of the data of pediatric malpractice cases from the Physicians Insurers Associations of America (PIAA) in 2000 found that there were 724 pediatric and adult meningitis claims during a 15-year period ending in 1999. Forty-three percent of these cases were closed with indemnity payments; the average payment was more than $308,000. The median age of these patients was 2 years; there were higher indemnities for younger patients. The PIAA also noted that death occurred in 30% of these cases; in 83% of the cases where death occurred, the patient was younger than 1 year. Noteworthy is that 7% of the defendants in these cases were ED physicians and that 30% of the initial contact with the patient was in the ED. In addition to fever, presenting symptoms included nausea, vomiting and flu-like symptoms, and lethargy. Neck stiffness was noted in only 10% of the cases. McAbee concluded that there was no such thing as too high an index for suspicion for meningitis in infants and toddlers and that performing a lumbar puncture is critical. Indeed, the pediatric adage that the proper time to perform a lumbar puncture is when it crosses your mind remains true today.
The aforementioned case indicates that any child with a fever and change in mental status must be evaluated for potential meningitis/encephalitis, assuming that all other tests are normal. Only with a normal spinal tap is it safe to discharge these patients. It also indicates the importance of being cognizant of and responsive to continuing parental complaints, manifested by telephone calls or revisits. The parent is often the best arbiter of the mental status changes in a child presenting with serious disease; parents' impressions should be considered carefully.
This case also touches upon the issues of experts in trials. The courts generally are liberal in allowing expert testimony. Some jurisdictions (e.g., Pennsylvania)12 specifically require that experts testifying regarding the standard of care be board-certified in the same discipline as the defendant(s). Even in these jurisdictions, however, the court will allow expert testimony if the plaintiffs' expert has an acknowledged expertise that will assist the jury, and that the expert" be substantially familiar with the applicable standard of care for the specific care at issue at the time of the alleged breach of the standard of care."12
Metabolic Disease
Metabolic etiologies of a change in mental status are diverse. The abnormalities include hyponatremia, hypokalemia, hypocalcemia, hypercalcemia, hypomagnesemia, hypermagnesemia, hypoglycemia, acidosis, hyperosmolar states, hypoxia, hepatic encephalopathy, uremia, and porphyria.1 For example, in diabetes mellitus, abnormalities in glucose, insulin, and glucose counterregulatory hormones levels can lead to abnormalities such as severe hyperglycemia or hypoglycemia. In addition, hyperinsulinemia in the newborn period can lead to severe hypoglycemia and associated mental status changes. Symptoms of hypoglycemia include tremors, palpitation, severe hunger, sweating, head-aches, irritability, mood changes, unresponsiveness, unconsciousness, and even seizures.13,14 It is critical that an fingerstick (e.g., AccuCheck or Dextrostick) test or serum glucose level measurement be evaluated by the ED physician evaluating a patient with a change in mental status.15 This is especially true in patients who are known to be diabetic because the common causes of hypoglycemia include insulin errors, unplanned exercise, omitted foods, alcohol ingestion, and drug abuse.16
Case #2. MacDonald v Chestnut Hill Hospital.17
A 2-day-old infant was discharged routinely from a small Philadelphia hospital after the mother had an uncomplicated labor and delivery. The child presented at approximately 6 days of age to the ED at the same hospital with extraordinary irritability and lethargy. Due to the lack of pediatric support, the child was transferred to another hospital for pediatric evaluation, and an LP was performed as part of the analysis. The patient was noted to have a low cerebral spinal fluid glucose level. Consequently, the serum glucose level was evaluated, and the patient was discovered to be severely hypoglycemic. The patient was resuscitated with glucose, and ultimately a diagnosis of hyperinsulinemia was made. Subsequently, the child suffered severe neurologic sequelae.
Suit was brought against both hospital EDs, as well as the nursery at the first hospital and individual emergency physicians. The plaintiffs contended that the child never had a routine heelstick glucose test throughout the nursery stay or during either ED evaluation. Plaintiffs' experts argued that that action was a breech in the standard of care—a contention not supported by the jury due largely to relatively poor plaintiff expert testimony. The jury verdict found for the defendants, although the case currently is being appealed by the plaintiffs.
Case #3. Scott v Porter.18
A 14-month-old child experienced two febrile seizures. In the ED, a CT scan and EEG revealed no abnormalities. After being discharged, the infant had a follow-up appointment with a neurologist, who concluded that he was fine. The infant had no significant medical problems until six months later, when the baby again had a seizure. At the hospital, he became nauseated and vomited several times in the x-ray room. Laboratory tests revealed a low serum sodium level. In contrast to the previous episode, these seizures were not the result of a fever. Finding no cause for the seizures, the patient was discharged from the ED, but he again seized shortly thereafter and was brought back to the ED. There, the baby was started on IV fluids using a hypotonic solution (D5 1/4 NS). Repeat laboratory tests again revealed hyponatremia. After another seizure, his IV rate was increased.
During a repeat CT scan, the child stopped breathing. He was intubated and placed on a ventilator. Again he was noted to be hyponatremic; an order was placed for a 3% normal saline solution, and he was transferred to a pediatric intensive care unit. By 3:15 p.m. that day, his brain had swollen to the point it was damaged too badly for him to survive. The child remained in a coma until his death a few days later.
A lawsuit was filed. Plaintiffs expert witness, a specialist in pediatric endocrinology, testified that the child died as a result of his already low blood sodium level being further diluted by the hypotonic solution, which had resulted in water passing into his brain causing it to swell. He advised the jury that the swelling brain compressed the nerves responsible for breathing. The expert witness testified that the standard of care had been breached when the physician failed to monitor the patient's blood sodium level after placing him on the diluted intravenous fluid. The jury awarded the child's mother $600,000 in actual damages, $1.5 million in punitive damages in the survival action, $1.5 million in actual damages, and $2 million in punitive damages in the wrongful death action. After the verdicts, the defendants moved for a new trial on the grounds that the verdict was grossly excessive. The appellate court, however, affirmed the judgment.
Analysis
A child with any suggestion of a change in mental status must have a reasonably complete metabolic and endocrinologic evaluation. The MacDonald case underlies the contention that all appropriate diagnostic interventions must be made as early as possible to avoid morbidity. The Scott case shows the importance of careful fluid resuscitation in small children. In terms of fluid resuscitation, children are more vulnerable than adults, and it is not difficult to cause severe osmolar changes with imprecise rehydration. Emergency medicine physicians should be comfortable with intravenous hydration and the management of electrolyte abnormalities in children. However, pediatric consultation should be considered if under the circumstances these therapeutic decisions prove challenging. In addition, the ED physician quickly should evaluate a fingerstick test and submit a complete serum metabolic evaluation shortly after the patient's arrival. The ED physician should be aware of the various other metabolic—and potentially correctable—diseases that may lead to abnormalities in mental status (e.g., hypothyroidism, diabetes, hyponatremia, and hypoxia).
Seizure Disorders
Seizures are relatively common and are treated frequently in the ED. Approximately 10% of the population will have one or more seizures in the course of their lifetime.19,20 Overall, complex partial seizures, which commonly can be manifested by an alteration in mental status, are the most common type across all age groups.20
Seizure disorders—specifically nonconvulsive status epilepticus or partial complex seizures —can be unusual causes of acute delirium or mental status changes.21-23 Multiple case studies suggest that an EEG should be utilized relatively early to evaluate seizure activity as an etiology of acute mental status changes in the ED.20,24 Although not a commonly litigated area, it is critical for the emergency physician to consider the diagnosis of a seizure disorder in these patients.
Case #4. Battle v Memorial Hospital.25
Daniel Battle, an 18-month-old child developed a fever and sores on his tongue. His mother took Daniel to his pediatrician who diagnosed an ear infection and tonsillitis and prescribed a course of antibiotics. Daniel's condition did not improve. Two days later, Mrs. Battle called and left a message with the pediatrician's answering service because Daniel's jaws were snapping shut. She then called 911 because Daniel's face had begun to twitch, and his eyes had rolled back. When the pediatrician called back, the paramedics had arrived and they informed him that Daniel had seizures, fever, and that one hand and his face were twitching.
Daniel was seen in the ED, and a lumbar puncture was performed, which was interpreted as normal. After x-rays and some blood work were performed, Daniel was diagnosed with febrile seizures, pneumonia, and an ear infection. He was discharged and went home with a new set of antibiotics.
The next day Daniel was continuing to have seizures. Mrs. Battle called her pediatrician and was instructed to take Daniel back to the Memorial Hospital ED. On this second trip, Mrs. Battle listed "self-pay" on the ED paperwork. Daniel was diagnosed with seizure disorder and pneumonia and administered Dilantin for the seizures. As Mrs. Battle took Daniel home with a prescription for additional Dilantin, she was instructed to "not bring that child right back in here because Dilantin takes time to work."
When the Dilantin wore off, Daniel's seizures returned and continued on and off throughout the day. That afternoon, Mrs. Battle called her pediatrician again, who instructed her to take Daniel to Memorial Hospital and have him admitted, which she did. A CT scan without contrast was read by the radiologist as normal. An EEG—which was not read until seven days later—was read as grossly abnormal.
The child ultimately was diagnosed with viral encephalitis; treatment was initiated with acyclovir, a drug that can halt the progression of herpes (the presumptive viral etiology) in some patients. Daniel subsequently was noted to be neurologically devastated in a near vegetative state.
Suit was brought against several ED physicians, their medical group, the pediatrician, and the hospital for medical negligence alleging that negligent medical treatment by defendant physicians resulted in injuries to the minor plaintiff and that defendant hospital was liable under the Emergency Medical Treatment and Active Labor Act (EMTALA) and state tort law. The suit included an EMTALA claim26 against the hospital, and, therefore, it was removed to federal court. The trial court granted summary judgment on behalf of the hospital on the state tort claim, secondary to an issue regarding the controlling statute of limitations, and the EMTALA claim due to lack of evidence of disparate treatment or failure to stabilize. The trial court also precluded admission of a videotaped deposition of plaintiffs' expert, due to his lack of availability for live testimony. The plaintiffs appealed the district court order granting summary judgment in favor of defendant hospital and individual physicians. The appellate court reversed the summary judgment in favor of the defendants, based on the court's exclusion of admissible testimony and precluded judgment as a matter of law on plaintiffs' EMTALA claims. As such, the matter was remanded for another trial.
Analysis
It is axiomatic that a diagnosis cannot be made, unless it is considered. Seizure disorders easily can be ignored or erroneously considered to be febrile seizures, but the diagnosis always should be entertained in the face of a change in mental status and appropriately evaluated and treated. In Battle, the defendants had promptly diagnosed the patient with a febrile seizure, which should be considered a diagnosis of exclusion. It is critical to attempt to ascertain the etiology of any new seizure in an organized and complete manner.
Although beyond the scope of this article, it is important to recognize the difference between tort law and EMTALA in risk management. The federal EMTALA (42 U.S.C.A. §1395dd (West 1995), was established to end the denial of medical care to certain individuals. The act is intended to give everyone access to necessary emergency care, and to avoid discrimination based on a patient's insurance status or lack of ability to pay. Included in those needing stabilization are those with an "emergency medical condition" or those in active labor.27 Nonstabilized patients may be transferred if the hospital is unable to completely stabilize the patient, and he or she is being transferred to a facility with more expertise. EMTALA includes provisions for civil penalties when a hospital violates its requirements. Likewise, a physician who violates EMTALA by transferring a nonstabilized patient can be held accountable. A physician may be prevented from participating in Medicare or Medicaid programs for repeated or egregious violations of EMTALA. Persons who suffer harm because of a hospital's violation of EMTALA can receive compensation from the hospital for any resulting personal injuries. A delay in examining or screening of a patient to ask about his insurance or method by which he will pay the bill also is forbidden under EMTALA.
A final point worth mentioning is that parents never should be told not to return to the ED as happened in the Battle case. It is often necessary to repeatedly evaluate pediatric patients, due to either parental noncompliance or excessive parental demands. It is better to err on the side of excessive re-evaluation of the child than to instruct parents to not seek care. A jury might become quite angry about instructions such as those given these parents.
Head Trauma
General and pediatric EDs evaluate head trauma on a daily basis.28,29 In the United States, this diagnosis is responsible for as many as 100,000 hospital admissions annually and approximately 30% of trauma-related mortality.30,31 The presentation in infants and young children of neurologic sequelae to head injury can be extraordinarily subtle.32 One study suggested that more than 80% of children who require neurosurgical intervention showed signs of mental status changes.33 The obvious problem for the ED physician is to determine the need for either hospitalization or imaging in these patients.
Case #5. Rahilley v. North Adams Regional Hosp.34
Mr. Rahilley's 5-month-old son Jeremy was having difficulty breathing while sleeping in his crib. The child was taken to the local ED. On arrival, he was "limp and pale, breathing at the rate of four respirations a minute," according to the hospital record. An attempt to intubate the patient was unsuccessful; the endotracheal tube was inserted into his esophagus rather than the trachea.
The child was transferred to a regional center "marginally responsive." A lumbar puncture was performed, which showed bleeding, and a CT scan was ordered. No CT scan had been performed at the first hospital, and none was performed until more than 4½ hours after the child's arrival at the tertiary care center. The CT scan showed intracranial bleeding as well as findings "consistent with generalized anoxia," according to court documents. It showed no evidence of increased intracranial pressure. The child subsequently died at the regional center with a final diagnosis of anoxic brain damage, intracranial hemorrhage, and aspiration pneumonia. The record also stated that the child was "found to have a significant intracranial bleed along with anoxic brain damage, verified by CT scan." There had been a question whether the child had been abused based upon the evaluation by the medical examiner. The father was charged with murder, but acquitted. Thereafter, he brought an action, alleging medical malpractice against the smaller regional hospital, the tertiary care center, numerous physicians, nurses, a respiratory therapist, and the transport service.
The plaintiffs' expert witness opined that the failure to rapidly perform a CT scan failed to meet accepted medical standards and contributed to the patient's eventual injury and death, and that a CT scan would have given this diagnosis, and that treatment would have then been undertaken to lower the intracranial pressure. Although initially the trial court held for the defendants, the appellate court reversed the decision and remanded the case for retrial. As such, the father was allowed to proceed with his claims against the pediatricians, the ED staff and the life-flight service.
Case #6. Rose v. Ikramuddin.35
In a small town in Kentucky, a 16-year-old boy was discovered lying semi-conscious on the sidewalk following an argument with other children. He was taken to an ED and evaluated by an obstetrician/gynecologist who was the physician in charge in the ED that night. The physician performed an examination and ordered skull x-rays and other laboratory tests. She interpreted the skull x-ray as normal and made the diagnosis of a drug overdose. The following morning, the child died, secondary to an epidural hematoma, presumably due to bleeding from a head injury that occurred during a fight. Allegedly, there was a diagnostic delay due to failure to perform a CT scan. The claim was that the skull films were not sufficient imaging, given the possibility of an intracranial bleed. Originally, the summons had not been timely served by the sheriff, and the physician was dismissed. The Appellate Court, however, remanded the court case for further action due to procedural issues.
Analysis
There are no simple unassailable rules regarding children who sustain head injuries. Obviously, the majority require no significant workup or intervention. A change in mental status, however, should be a clear sentinel of potentially significant injury, leading to careful evaluation.
In the Rahilley case, there can be a reasonable argument that imaging was not possible due to the ongoing resuscitation of the patient. Obviously, if a jury is told that the child would have improved magically with CT imaging and neurosurgical intervention, then, it is difficult for a defendant to prevail in this kind of case. In the Rose case, a poor result might have been avoided if: 1) the appropriate imaging (i.e., a CT scan instead of a skull film) had been performed, and 2) the drug intoxication diagnosis had been treated as a diagnosis of exclusion as mentioned above.
Stroke
In adults, rapid neuroimaging of a patient who has suffered a stroke is critical to the decision to use thrombolytic therapy.36 Although stroke is unusual in children and thrombolytic therapy is rarely used, it is still incumbent to rapidly diagnose stroke in pediatric patients. The ED physician must be mindful of unusual presentations of cerebrovascular disease to promptly evaluate a potential stroke patient. Although the majority of strokes are diagnosed because of specific new-onset neurologic deficits, a stroke victim can present with an alteration in mental status. In addition, the ED physician must be aware of some of the more infrequent causes of cerebrovascular accidents.37
Interestingly, hemorrhagic stroke is more commonly associated with changes in mental status than ischemic stroke.38 Causes of strokes in children are multifactorial, and distinct changes in mental status occur in 28% of ischemic stokes and in 88% of hemorrhagic strokes in pediatric patients.39
The most common vascular anomaly associated with strokes is moyamoya disease. Moyamoya disease is a rare, chronic occlusive cerebrovascular disorder characterized by two important features: progressive bilateral stenosis of the arteries of the Circle of Willis and formation of small capillary-sized vessels that provide collateral blood flow. Angiographically, these abnormal reticular vessels look like a puff of smoke, which brings about a hazy, or moyamoya (i.e., "misty" in Japanese) appearance.40 Most cases are idiopathic, but some are found in association with other conditions (e.g., Down syndrome, congenital heart disease, and sickle cell disease).41,42 Other common etiologies include the vasculopathy associated with sickle cell disease.41 In addition to sickle cell disease, numerous other coagulopathies are associated with an increased risk for stroke. These include thrombotic thrombocytopenia purpura (TTP), immune thrombocytopenia purpura (ITP), and protein C, protein S, and antithrombin III deficiencies.43 Protein C deficiency has been linked to stroke and venous thrombosis. Finally, some types of chemotherapeutic agents (e.g., asparaginase) are prothrombotic.43 The rarity of cerebrovascular accidents in children and the associated morbidity make the risk of litigation considerable.
Case #7. Samiyah Williams v. Children's Hospital.44
A child suffered multiple complications of sickle cell disease including transient neurologic changes and ultimately a cerebrovascular accident. The child's mother brought suit against a major children's hospital and various physicians. She claimed that a delay in the diagnosis of moyamoya disease associated with her child's underlying sickle cell disease precluded her from receiving definitive surgery to correct this disorder, contributing to her neurologic deterioration. The child previously had been diagnosed with a sickle cell-related vasculopathy and was prescribed transfusion therapy. The medical records revealed that there had been general noncompliance with the transfusion schedule. A cerebrovascular accident and MRI/ MRA revealed moyamoya syndrome. Allegedly, this was not reported to the hematologists caring for the patient and, therefore, there was no neurosurgical consultation. A subsequent stroke led to severe catastrophic deterioration. Plaintiffs argued that they were denied the opportunity to seek neurosurgical correction of the underlying vasculopathy. Defendants argued that there was no causation because neurosurgical intervention in these cases was highly experimental and not within the accepted standard of care. This argument was successful and in a Frye hearing, the case was dismissed. (In Pennsylvania, the judge can allow a Frye hearing to determine if there is any scientific validity to the arguments of the experts, based on Frye v. United States, 54 U.S. App. D.C. 46, 293 F. 1013 (D.C. Cir. 1923). The judge acts as a "gatekeeper" allowing only scientifically valid expert testimony to reach the jury.)
Analysis
It is important to be aware of the underlying diagnoses that predispose to cerebrovascular accidents, and to not overlook preventative therapy. The long-term consequences of severe stroke make litigation awards extraordinarily high in these cases when such awards are given.
Although the use of t-PA and other thrombolytic agents has been shown to be of minimal value, especially in children, plaintiffs can point to potential harm in the delay of diagnosis of thrombotic events, pointing to the three-hour window of efficacy. As such, it is important to consider stroke in a patient with changes in mental status and even more so in those patients with significant risk factors. Because strokes are unusual in children, this diagnosis can be overlooked. In patients with risk factors such as sickle cell disease or thrombophilic tendencies, it is critical to appropriately image the patient who presents with neurologic change. In addition, the patient and parents must be cognizant of any risk factors that may affect other therapies. For example, an adolescent girl who is prothrombotic should be cautioned against the use of birth control pills, which are themselves, prothrombotic. In some patients, aspirin prophylaxis may be protective and advisable, even at an early age. Finally, prothrombotic tendencies may be of significance in genetic counseling of either the parent or the child as they grow older.
Intoxication
Pediatric toxicologic concerns account for more than 130,000 presentations to EDs each year.45,46 Substance abuse remains a complex problem for the ED practitioner, although the group for which the highest rates of illicit drug is 18-25-year-olds.47-52 Drugs of abuse include inhalers, tobacco, alcohol, marijuana, amphetamines, cocaine, opiates, hallucinogens, anabolic steroids, and others. Alcohol problems are a leading cause of preventable illness and injury and represent a substantial portion of the 95 million ED visits each year.52 Alcohol ingestion accounts for approximately 60% of comatose patients presenting to the ED; many are adolescents or young adults.3 The key to excellent care in the ED is to rule out other potential causes of altered mental status, even in patients who clearly are intoxicated. Any patient presenting to the ED with a change of mental status needs to be evaluated for possible use and/or abuse of drugs. Treatment of substance abuse in patients is often a combination of behavioral and medical interventions.53 A detailed recitation of this problem and the evaluations and treatment of substance abuse is well beyond the scope of this article. However, missed diagnoses can lead to litigation based upon both the short- and long-term problems associated with substance abuse, as well as potential third party liability. In addition, infants with limited glycogen stores can be at higher risk for hypoglycemia after toxic exposure, specifically with agents such as ethanol.40
Overingestion of therapeutic drugs is also a potential etiology of mental status changes in the ED. A complete and accurate history is critical in the evaluation of a patient when intoxication is suspected. The acquired information may determine the options for gastrointestinal decontamination and/or decisions for the use of toxicology screens.53,54
Case #8. Walling v Flint Osteopathic Hospital, et al.55
Ms Walling, a minor, was involved with a group of older teenagers, who illicitly purchased a substantial quantity of liquor. After significant alcohol intake, she became ill and disoriented and went to an ED. She was informed that permission was needed from a parent or other responsible adult before the hospital would treat her. Ms. Walling refused to disclose her parents' telephone number and, prior to evaluation the patient eloped from the hospital ED. The patient subsequently was killed in a house fire because of her unresponsiveness, and, as part of the matter, the hospital ED was sued for malpractice in allowing her elopement. Ms. Walling's executors contended that the hospital failed to examine and treat the minor. They also alleged an EMTALA violation based upon the "discharge" of the "unstabilized" patient. The court ultimately ruled that the hospital did not have a duty under Michigan law to treat the minor without the prior consent of the minor's parents because the minor did not present herself in a condition that would constitute an unmistakable medical emergency. As such, there was also no EMTALA violation.
Analysis
It is incumbent for the ED practitioner to be aware of the specific limitations of the routine drug screens and the wide availability of both therapeutic and recreational drugs to the child. The aforementioned case also leads to a discussion of treatment of a child in the absence of his/her parent. The first and foremost consideration must be the welfare of the child. If the child is unemancipated and presents without a parent, it is incumbent upon the ED physician to provide the necessary care and a medical screening evaluation under EMTALA and, if necessary, discuss the legal ramifications with the appropriate personnel in legal office of the hospital.
Intussusception
The classic presentation of intussusception is a combination of abdominal pain, vomiting, and "currant jelly" stools in children 3-9 months of age. Interestingly, it is been shown that profound lethargy associated with intussusception in children is a hallmark of this disease.50 Because this is a unique characteristic of a pediatric illness, it is worth mentioning in this context.
Case #9. Kern v. St. Luke's Hospital Assn.56
Mr. Kern, a 14-month-old child, became violently ill, lethargic, and began to vomit. He was seen in the ED by a physician only one month into his residency. The resident, allegedly unsupervised, concluded that the child had gastroenteritis and discharged him. The patient slept through the night and began vomiting again the following day. He was reexamined in the office of the pediatrician, and an intussusception was suspected. The patient was admitted, and a barium enema was performed. That evening a surgeon was consulted who also palpated a round mass the child's abdomen and recommend-ed that the barium enema be repeated. It was not performed until the following morning because the condition of the child was perceived as being im-proved. However, the child subsequently became extraordinarily listless. An operation was performed, and a bowel blockage secondary to intussusception was corrected. There were six inches of gangrenous intestine, which led to severe postoperative complications.
A lawsuit was filed alleging that there was a significant delay in the diagnosis of an intussusception, leading to necrotic bowel and subsequent neurologic damage. Initially, the trial court found on behalf of the defendant hospital and ED physicians. Due to several issues of potential legal misconduct on part of the defense, specifically, inappropriate innuendo regarding the economic relationship between the plaintiffs' counsel and the plaintiffs' experts, the case was remanded for further action.
Analysis
It is important that the practitioner familiarize him or herself with the unique signs and symptoms of pediatric conditions, such as intussusception. In cases where the ED practitioner is uncomfortable, pediatric consultation is justified and warranted. Intussusception is a unique diagnosis in pediatric patients and one that is specifically associated with changes in mental status. Again, for the ED physician who does not frequently treat children, it is advisable to obtain pediatric consultation in this setting.
Conclusion
It is critical to carefully evaluate a pediatric patient especially regarding mental status. This task can be difficult, especially in the young child in whom mental status is difficult to evaluate in the best of circumstances. The aversion of the child to the ED environment may make this determination more difficult, and the patient may be generally uncooperative. If there is a question in the mind of the practicing ED physician as to the baseline mental status and any changes, it is possible to ask for appropriate pediatric consultation. The morbidity of the conditions with which changes in mental status can be associated is severe, and the medicolegal ramifications are immense. Any perceived changes should be evaluated carefully, and an intensive workup is indicated to prevent poor results and potential malpractice suits.
Endnotes
1. Martini D. Delirium in the pediatric emergency department CPEM - 2004 Sep; 5(3);173.
2. Watemberg N, Willis D, Pellock JM. Encephalopathy as the presenting symptom of Hashimoto's thyroiditis. J Child Neurol 2000;15:66-69.
3. Turkel SB, Tavare CJ. Delirium in children and adolescents. J Neuropsychiatry Clin Neurosci 2003;15:431435
4. Paul SR. Pediatric Fever: It could be more than a warm forehead. ED Legal Letter 2004;15:109-120.
5. Losh D. Central nervous system infections. Clin Fam Pract 2004; 6;1.
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As if communication with young children was not challenging enough, the child presenting with an altered mental status (AMS) is an exceptional opportunity for testing one's sleuthing ability. The reality is that we see far more adults with AMS than we do children. Consequently, we might be tempted for just a moment to doubt our abilities.Subscribe Now for Access
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