Projekt Beschreibung

Disturbance of consciousness of unknown cause

History:

A 1 year and 4 months old girl was referred by a peripheral hospital due to impaired consciousness of unknown cause. The mother reported, that the child could not be properly roused after having taken a nap at the daycare. The child’s behavior in the morning had been normal.
There was no history of a trauma or infection. The daycare stated, that the child had no access to any drugs or other substances.
In her past medical history there were no major illnesses and her immunizations were up to date.
The mother reported, that the child only called “Mom” once, but was otherwise not communicating with her. To her, the girl seemed to behave very differently than usual.

Clinical findings:

On examination the patient was agitated and only consolable for short periods of time.
Respiration and circulation were stable, except for a slight tachycardia of 113-149 bpm and an arterial hypertension of BD 139/79 mmHg.
The patient did not open her eyes, did not obey commands or react adequately to voice or touch of her mother, but was localizing to pain. There were no lateralization signs, reflexes and muscle tone were normal, but she showed some neck stiffness.
There were no haematoma or other clinical signs for a trauma. There was mild redness of the right upper eyelid. ENT examination was normal.

Quiz

What would you recommend to be done next?

The correct answer is "Oxybuprocaine eye drops"


After the application of oxybuprocaine eye drops the child opened her eyes spontaneously and her behavior was completely normal. When she was relaxed and pain free, her neck stiffness completely resolved.

Toxicology Screening needs to be considered in cases of disturbed consciousness of unknown cause and a urine specimen collected. In this case, the application of oxybuprocaine eyedrops gave us the solution before the urine specimen was obtained.

A lumbar puncture would be indicated in cases of suspected encephalitis. Consider imaging first in cases of disturbance of consciousness of unknown cause. In this case, the application of oxybuprocaine eyedrops gave us the solution before cerebrospinal fluid was obtained.

A CT scan can be indicated to rule out any bleed or mass. It would have been the next step, if oxybuprocaine eyedrops had not given us the clue

MRT Scans at this age require sedation of the child and are rarely used in emergency (stroke!). A CT scan, although with the drawback of radiation, would be the imaging of choice in an acute disturbance of consciousness of unknown cause. In this case, neither one was necessary, as oxybuprocaine eyedrop application helped finding the cause.

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What is your next step?

The correct answer is "apply fluoresceine"


If oxybuprocaine eye drops lead to such an improvement of the pain, fluoresceine eye drops should be applied to look for corneal lesions. The diagnosis of a corneal lesion was confirmed by applying fluoresceine eye drops in this patient.


Before the child is discharged, further checks are needed, therefore answer 1 is wrong.


Glaucoma is very rare in children and the pain would not improve with local anesthetics, therefore measuring the intraocular pressure is not indicated.



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In patients with corneal lesions these further examinations are indicated:

The correct answer is "all of the above".

- Check pupillary reaction


- Check for hyphema


- Look for foreign bodies including ectropionizing of the upper eye lid especially if vertical lesions are present


- Slit lamp examination in bigger lesions to exclude corneal perforation


 


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Management of corneal lesions

Avoid removing large, deep or central corneal foreign bodies, refer these to ophthalmology.

After a foreign body has been excluded or removed, patients with corneal lesions are treated with antibiotic eye drops or ointment, e.g. Ofloxacin drops 4x/per day and ointment during the night or ointment only 3x per day for 3-5 days or longer depending on the lesion.
If the child tolerates it, a dressing can be applied, to prevent him/her from scratching. The first 4 hours after local anaesthetic drops, it is essential to keep the child from touching his/her eye. A pad can be applied longer to ease pain, but any pressure on the bulbus should be avoided.

An ophthalmologist should see lesions lying within the visual axis or lesions causing pain for > 24h. Smaller lesions outside of the visual axis should be followed up by the pediatrician within days.

Corneal lesions due to chemicals need urgent irrigation over about 15 minutes until pH is normal (6-8) and should be discussed with an ophthalmologist.