Causes of Pediatric Agitation – Help From Pediatric EM Morsels

Whenever you have an agitated pediatric patient who is a danger to herself or others be sure to review Dr. Fox’s brief outstanding post (Pediatric) Agitation. Below are some of the causes of pediatric agitation. For Dr. Fox’s treatment recommendations please click on the post link above. CME is available

Here are the causes of agitation excerpted from Dr. Fox’s post above so consider each cause carefully [And finally, at the end of Dr. Fox’s list,I have added an additional cause of agitation and/or acute mental status change and/or encephalitis-Autoimmune Brain Disorders*]:

Undifferentiated agitation (abridged) Ddx:

  • Broad Categories:
    • Medical Conditions
    • Substance Use
    • Psychiatric illness
  • AEIOU TIPS (yes… this is the one for Altered Mental Status… I’m not smart enough to remember more than one acronym)
    • Alcohol – while often a sedative, ETOH can cause agitation
    • Electrolyte derangements (ex, hyponatremia, hypercalcemia)
    • Insulin (got hypoglycemia??)
    • Opiates and Other Drugs (got a toxidrome? anticholinergic vs sympathomimetic? NMS? Serotonin syndrome?)
    • Uremia
    • Trauma – Look closely for signs of trauma
    • Infection – Meningitis/encephalitis?
    • Psychiatric disorder – really should be the last one considered
    • Space occupying lesion
  • [Autoimmune Brain Disorders*]

*We also want to think of autoimmune diseases of the central nervous system as a cause of acute agitation and encephalitis. From Oxford Neuroscience see Diagnosing autoimmune diseases of the nervous system. The following is an excerpt from that page:

Angela Vincent’s team have also shown that autoantibodies targeting potassium channel (VGKC) and associated proteins, and the NMDA receptor, can be the cause of two different forms of encephalitis which many would previously have thought were due to viral infections.  Crucially,  as autoimmune brain disorders often respond dramatically to immunosuppressive therapy, these findings provide new hope for these patients. As a result the European Federation of Neurological Societies, the Association of British Neurologists and the British Infection Association guidelines all recommend that potential autoimmune causes of encephalitis should be high on the list of possible diagnoses.  In this way effective treatment can often be provided earlier.

The success of Angela Vincent’s work led to the creation of the first, and the largest, Clinical Neuroimmunology service to test NHS samples in the UK. Providing the optimal antibody testing for another disease, neuromyelitis optica, supports the NHS national service established between Oxford and Liverpool for the clinical care of these patients.  Demand for the service overall has expanded fivefold in recent years and in 2012 over 27 thousand samples were tested; mostly from the NHS but also from across Europe and elsewhere. Any proceeds from this service are fed back into improving antibody testing as well as frontline medical research.

Here is a link to Anti-N-methyl-d-aspartate receptor encephalitis: review of clinical presentation, diagnosis and treatment [PubMed Abstract] [Full Text HTML] [Full Text PDF]. BJPsych Bull. 2015 Feb; 39(1): 19–23.
doi: 10.1192/pb.bp.113.045518

And here is a link to Anti-N-Methyl-D-Aspartate Receptor Encephalitis, an Underappreciated Disease in the Emergency Department [PubMed Abstract] [Full Text HTML] [Full Text PDF]. West J Emerg Med. 2016 May; 17(3): 280–282.
Published online 2016 May 2. doi: 10.5811/westjem.2016.2.29554

For medications and dosages for acute pediatric agitation, see Dr. Fox’s post (Pediatric) Agitation. Be sure and also review all the excellent references Dr. Fox includes his post.

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