Altered mental status (peds)
This page is for pediatric patients. For adult patients, see: altered mental status
Background
- Both cerebral cortices must be affected to cause altered mental status
- Must quickly determine if coma or lethargy is from diffuse or focal impairment
Clinical Features
- Depends on cause
- Diffuse brain dysfunction - lack of focal findings
- Focal brain dysfunction - hemiparesis, loss of motor tone, loss of ocular reflexes
- Important to differentiate diffuse brain dysfunction from localized lesion as a patient may appear confused due to visual deficit, dysphasia, etc.
Differential Diagnosis
| A | Alcohol | O | Opioids |
| Acid-base and metabolic disorders | U | Uremia | |
| Diabetes mellitus | Chronic renal failure | ||
| Dehydration | Hemolytic-uremic syndrome | ||
| Hypercapnia | T | Trauma | |
| Hepatic failure | General trauma with hypovolemia | ||
| Hypoxia | Head injury | ||
| Inborn errors of metabolism | Mass lesion | ||
| Arrhythmia and cardiogenic causes | Cerebral edema | ||
| Ventricular fibrillation | Cerebrovascular accident | ||
| Adams-Stokes attack | Electric shock | ||
| Aortic stenosis | Decompression sickness | ||
| Pericardial tamponade | Tumor | ||
| E | Encephalopathy | Hyperthermia, hypothermia | |
| Hypertensive encephalopathy | I | Infection | |
| Reye syndrome | Meningitis | ||
| Pediatric shock|Hemorrhagic shock]] and encephalopathy syndrome | Encephalitis | ||
| Brain abscess | |||
| Postimmunization encephalopathy | Visceral larva migrans | ||
| Disseminated encephalomyelitis | Severe systemic infection | ||
| Human immunodeficiency virus disease | Intracerebral vascular disorders | ||
| Subarachnoid hemorrhage | |||
| Endocrinopathy | Venous thrombosis | ||
| Addison's disease | Arterial thrombosis | ||
| Congenital adrenal hyperplasia | Intracerebral or intraventricular hemorrhage | ||
| Thyrotoxicity | |||
| Cushing syndrome | Cerebral embolus | ||
| Pheochromocytoma | Acute infantile hemiplegia | ||
| Hepatic porphyrias | Acute confusional migraine | ||
| Electrolyte abnormalities | Moyamoya malformation | ||
| [Na+], [Ca2+], [Mg2+], PO4 |
P | Poisoning | |
| I | Insulin | Psychogenic unresponsiveness | |
| Hypoglycemia | S | Seizure | |
| Ketotic hypoglycemia | VP shunt malfunction |
Additional[1]
- Sympathomimetics/cocaine
- Anticholinergics
- Arsenic
- LSD
- PCP
- Phenothiazines
- Salicylates
- Theophylline
- Thyroxine
Evaluation
- Labs
- Glucose, CBC, chem, UA, CSF, LFT, utox, VBG, BAL, thyroid, Calcium (ionized)
- ECG
- Neuroimaging
- XR
- UA
Management
- Immobilize cervical spine for suspected trauma
- Fluid resuscitation 20 mL/kg x3 as needed; start pressors thereafter
- Antibiotics for sepsis or meningitis (consider antiviral it patient is toxic)
- Naloxone for opioid or clonidine overdose (0.01-0.1mg/kg IV q2 min)
- Glucose for hypoglycemia (2 mL/kg of 25% dextrose)
- Avoid sodium bicarbonate for metabolic acidosis unless pH <7.0
- Control seizures
- Prevent hypothermia, treat hyperthermia
See Also
- Altered Mental Status
References
- Source APLS page 182, 5th ed.
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