Pediatric emergency medicine trisk 2732 2732
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (46.01 KB, 1 trang )
An oncology-directed history, with particular attention to a detailed medication
history, is critical to narrowing the differential diagnosis. Physical examination
should look for other findings such as papilledema or focal neurologic findings that
may also narrow the differential diagnosis. Laboratory evaluation should be carried
out as recommended in Chapter 97 Neurologic Emergencies . If a drug-related cause
is suspected, specific drug levels when available may be helpful. If a lumbar
puncture is planned to look for malignant cells or an infectious etiology, the risk of
herniation should be assessed. Imaging studies may be appropriate if an intracranial
lesion is suspected or when the diagnosis is unclear. A CT scan without contrast can
be useful to identify midline shift, increased ventricular size, or a hemorrhagic
stroke. A CT scan with contrast can identify likely carcinomatous meningitis or a
supratentorial mass lesion. MRI can identify mass lesions anywhere in the CNS
including below the tentorium, ischemic stroke, hypertensive encephalopathy, or
encephalitis.
Management of drug-related altered mental status usually involves withholding
the offending agent and supporting the patient until return to baseline. If narcoticrelated, avoid rapid and complete reversal with standard doses of naloxone, which
could cause excruciating pain that will be unresponsive to further narcotics for 2 to 3
hours. Supportive care such as stimulation should be tried prior to reversal. If
reversal is required, the appropriate dose of naloxone (0.1 mg/kg) should be diluted
in 10 mL of normal saline and then administered in 1-mL aliquots while titrating to
effect. Alternatively, dosing can be initiated at 1 µg/kg for mild respiratory
depression and 10 µg/kg for reversal of moderate to severe respiratory depression as
needed. Laboratory evaluation of hepatic and renal function may identify
contributing factors to increased drug effect. If ifosfamide neurotoxicity is
suspected, many recommend methylene blue treatment using dosages that have been
extrapolated from other settings. The usual dose for adolescents and adults is 50 mg
administered orally or by slow IV push. There is no clear dosage for younger
children but there are case reports using 1 to 2 mg/kg as in the treatment for
methemoglobinemia. For management of hypertensive encephalopathy, see Chapter
37 Hypertension .
