Altered mental status in children is failure to respond

to verbal or physical stimulation in a manner appropriate to the

childs developmental level

Children with altered mental status require simultaneous

stabilization, diagnosis, and treatment

The objectives of treatment are to

sustain life and prevent irreversible central nervous system damage

Once the patient is resuscitated, the next objective is to establish the

cause and stop disease progression

PATHOPHYSIOLOGY

The spectrum of alteration of mental status ranges from confusion or delirium

(disorders in perception) to lethargy, stupor, and coma (states of
decreased awareness).

lethargic child has decreased awareness of self

and the environment. In the ED, this translates to decreased eye contact

A stuporous child has

decreased eye contact, decreased motor activity, and unintelligible vocalization
Stuporous patients can be aroused with vigorous noxious stimulation.

Comatose patients are unresponsive and cannot be aroused by

verbal or physical stimulation

altered mental status indicates depression of

the cerebral cortex or localized abnormalities of the ascending reticular
activating system.

Typical causes of bilateral cortical impairment are

toxic and metabolic states

The pathologic conditions that affect awareness and arousal can be divided
into three broad pathologic categories: supratentorial mass lesions,
subtentorial mass lesions, and metabolic encephalopathy.

Signs and symptoms of this type of lesion include focal motor abnormalities,
which are often present from the onset of the altered level of
consciousness. The progression of neurologic dysfunction is from rostral
to caudal

Subtentorial mass lesions lead to reticular activating system dysfunction,

in which prompt loss of consciousness is generally the rule. Cranial
nerve abnormalities are frequent, and abnormal respiratory patterns,
such as Cheyne-Stokes respiration, neurogenic hyperventilation, and
ataxic breathing, are common

With brainstem injury, asymmetric and/

or fixed pupils are found.

Metabolic encephalopathy usually causes depressed consciousness before

motor signs become depressed. Motor signs are typically symmetric. Respiratory
abnormalities are usually secondary to acid-base imbalance. Pupillary
reflexes are generally preserved.

Pupils may be sluggish, but pupil

responses are intact and symmetric, except in the case of profound anoxia
or poisoning with cholinergics, anticholinergics, opiates, or barbiturates.

CLINICAL FEATURES
prodromal events before the change in consciousness
recent
illnesses or infectious exposures,

determine the likelihood of trauma

or abuse
Ask about antecedent fever, headache, head tilt, abdominal
pain, vomiting, diarrhea, gait disturbance, seizures, drug ingestion, palpitations,
weakness, hematuria, weight loss, and rash.

review developmental milestones

medical, immunization,
and family histories

Proceed with a general examination only after respiratory, cardiac,

and cerebral resuscitation

The objectives of the examination are to identify

occult infection, trauma, toxicity, or metabolic disease

The neurologic
examination should document the childs response to sensory
input, motor activity, pupillary reactivity, oculovestibular reflexes, and
respiratory pattern.
the most simplified and functional coma scale in an emergency setting is the AVPU

This is a descriptive tool in which A means alert, V means responsive

to verbal stimuli, P means responsive to painful stimuli,
and U means unresponsive. The A, V, P, and U values correspond
to Glasgow Coma Scale scores of 15, 13, 8, and 3 respectively.

DIAGNOSIS

AEIOU TIPS (alcohol, encephalopathy, insulin,

opiates, uremia, trauma, infection, poisoning, and seizure)

DIAGNOSTIC EVALUATION
Diagnostic
tests should be guided by the clinical situation

blood glucose level

Procedures for diagnosis of causes of altered mental status include analysis

of blood, urine, and cerebrospinal fluid (CSF); electrocardiography; and
diagnostic imaging

If the history is
consistent with a toxic ingestion or a toxidrome is identified, serum or
urine toxicology screening
An arterial blood gas or capillary blood gas analysis with pulse oximetry
may provide useful information in cases of trauma, respiratory distress,
or suspected acid-base imbalance.

Obtain a 12-lead ECG if there are pathologic auscultatory findings or

a rhythm disturbance is observed while monitoring the patient. An ECG
may further guide therapy in cases of tricyclic antidepressant overdose.
Imaging is directed by the clinical scenario. Cervical spine immobilization
is the first step in management of the patient with head or multiple
system trauma, followed by cervical spine radiography and/or CT of
the cervical spine and head. A chest radiograph confirms or clarifies examination

findings and documents endotracheal tube placement. Abdominal

radiographs are indicated if the acute ingestion of radiopaque
material is suspected or if the patient exhibits signs and symptoms of an
acute abdomen, including possible intussusception. Abdominal US
studies may be useful to screen for cases of intussusception with an atypical
presentation. A CT scan of the head may be obtained for suspected
increased intracranial pressure, vascular disorder, or mass lesion. Magnetic
resonance neuroimaging may be arranged for children at high risk
who have had a first seizure

SPECIFIC CONDITIONS CAUSING ALTERED MENTAL STATUS

TREATMENT
Table 131-2.

DISPOSITION AND FOLLOW-UP

Children with altered mental status require admission to an intensive
care unit