How to assess a paediatric patient’s mental status
I think head injuries is one of the most common questions I get asked when teaching so here is some advice to help.
Copied from the EMS1.com website
Spend time with infants and toddlers to learn and understand ‘normal’ responses
With a sickening thud, my two-year-old’s head slammed into the concrete. Despite three stern parental warnings she leaped off the front step, landed on the ice, went airborne, and cratered into the sidewalk. I feared the worst — open head wound and traumatic brain injury — when I began my assessment.
Assessing mental status in infants and toddlers is more complex than adults because they generally can’t tell the date, time, precise location, or preceding events. Kids under two might not even be able to report their name when healthy. My wife asked my daughter, “Where are you?” She literally interpreted her question and answered, “Right here.”
These are tips for gauging the mental status of infants and children:
- Ask available parents and/or caregivers.
As they know the child, they can tell you if the child’s mental status is normal or abnormal.
- Know age-related norms.
Infants are generally pretty comfortable being around and handled by strangers. Toddlers are more likely to exhibit stranger anxiety. An older toddler should know basic things like their own name, age, where they live, and/or their parent’s names.
- Recall of recent activities and favourite things.
Toddlers can recall recent events like what they had for lunch or an activity they were just playing. Check longer term memory by asking a toddler about their favourite toy, game, or memory.
- Ask the child to perform a simple task.
Try things like touch your nose, cover your ears, close your eyes, or make a big mouth.
- Know normal.
Spending time around kids is the best way to learn what is normal. Take advantage of injury prevention programs or community education events to interact with infants, toddlers, and their parents. Ask questions to see what toddlers are normally able to answer on their own.
My daughter survived her fall with only a painful reminder to listen to her daddy. Although she had a wound that required a few stitches she had no altered mental status and no loss of consciousness. She was lucky and I was relieved.
When to and when not to refer a head injury to the Emergency Department (ED) / Accident & Emergency (A&E). There is no real answer to this one except if in doubt refer and let the ED triage staff decide. Below is a letter from the Royal College of Paediatrics and child health where it is recommended that under twos be seen in the ED.
Advice from the NHS is:
Minor head injuries are common in people of all ages and should not result in any permanent damage.
The symptoms of a minor head injury are usually mild and short lived. Symptoms may include:
- a mild headache
- nausea (feeling sick)
- mild dizziness
- mild blurred visionIf your symptoms significantly worsen or you develop any new symptoms after being discharged, you should return to A&E straight away or call 999 and ask for an ambulance.
There are a number of self-care techniques you can use to relieve mild concussion symptoms. If more serious symptoms start to develop, seek immediate medical treatment.
Some self-care techniques for mild symptoms of concussion are outlined below.
- If you or your child experience these mild symptoms after a knock, bump or blow to the head, you won’t usually require any specific treatment. However, you should go to your local accident and emergency (A&E) department for a check-up.
- apply a cold compress to the injury to reduce swelling – a bag of frozen vegetables wrapped in a towel could be used, but never place ice directly on the skin as it’s too cold; apply the compress every two to four hours and leave it in place for 20 to 30 minutes
- If you or your child experience minor symptoms after a knock, bump or blow to the head, you won’t usually require any specific treatment.
You should visit your nearest accident and emergency (A&E) department if you or someone in your care has a head injury and develops the following signs and symptoms:
- loss of consciousness, however brief
- memory loss, such as not being able to remember what happened before or after the injury
- persistent headaches since the injury
- changes in behaviour, such as irritability, being easily distracted or having no interest in the outside world – this is a particularly common sign in children under five
- drowsiness that occurs when you would normally be awake
- loss of balance or problems walking
- difficulties with understanding what people say
- difficulty speaking, such as slurred speech
- problems with reading or writing
- vomiting since the injury
- problems with vision, such as double vision
- loss of power in part of the body, such as weakness in an arm or leg
- clear fluid leaving the nose or ears (this could be cerebrospinal fluid, which surrounds the brain)
- sudden deafness in one or both ears
- any wound to the head or face