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

• 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

Disposition

• Admit to PICU:
  • GCS ≤12 or declining neurologic status
  • Requirement for intubation or airway protection
  • Active seizures or status epilepticus
  • Suspected CNS infection requiring IV antibiotics and monitoring
  • Hemodynamic instability
  • Suspected ingestion requiring monitoring or antidote infusion
• Admit to floor:
  • Stable AMS with identified treatable cause requiring observation
  • Metabolic derangement requiring correction and monitoring
• Discharge:
  • Fully resolved AMS with identified benign cause (e.g., febrile seizure with return to baseline)
  • Reliable follow-up arranged
  • Caregivers given clear return precautions

See Also

• Altered Mental Status

External Links

• Pediatric Emergency Playbook Podcast: Altered Mental Status in Children