Altered mental status (peds): Difference between revisions

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Both cerebral cortices must be affected to cause altered mental status The objectives of the examination are to identify occult infection, trauma, toxicity, or metabolic disease
{{PediatricPage|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


Although several coma scales have been published, the most simplified and functional in an emergency setting is the AVPU scale. 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.7
==Clinical Features==
*Depends on cause
**Diffuse brain dysfunction - lack of focal findings
**[[focal neuro deficits|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.


AEIOU TIPS (alcohol, encephalopathy, insulin, opiates, uremia, trauma, infection, poisoning, and seizure
==Differential Diagnosis==
 
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===Additional<ref>Source APLS page 182, 5th ed.</ref>===
*[[Sympathomimetics]]/[[cocaine]]
*[[Anticholinergics]]
*[[Arsenic]]
*[[LSD]]
*[[PCP]]
*[[Phenothiazines]]
*[[Salicylates]]
*[[Theophylline]]
*[[levothyroxine|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
*[[pediatric antibiotics|Antibiotics]] for [[sepsis]] or [[meningitis]] (consider [[antiviral]] it patient is toxic)
*[[Naloxone]] for [[opioid toxicity|opioid]] or [[clonidine toxicity|clonidine overdose]] (0.01-0.1mg/kg IV q2 min) 
*[[dextrose|Glucose]] for [[hypoglycemia (peds)|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==
*[http://pemplaybook.org/podcast/altered-mental-status-in-children/ Pediatric Emergency Playbook Podcast: Altered Mental Status in Children]


==References==
<references/>


 
[[Category:Pediatrics]] [[Category:Neurology]]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
== Treatment ==
 
Assess airway, breathing, and circulation. Immobilize cervical spine for suspected trauma. Initiate continuous pulse oximetry; consider capnometry; administer oxygen. Provide fluid resuscitation, 20 mL/kg x3 as needed. Administer antibiotics for suspected sepsis or meningitis. Give naloxone for suspected opiate or clonidine overdose, 0.01 to 0.1 milligram/kg IV every 2 min. Administer flumazenil for suspected pure benzodiazepine overdose, 0.01 milligram/kg IV. Give glucose for hypoglycemia, 2 mL/kg of a solution of 25% dextrose in water IV. Avoid sodium bicarbonate for metabolic acidosis unless pH is <7.0. Control seizures. Prevent hypothermia with heat lamps during resuscitation, treat hyperthermia.
 
If there is clinical suspicion of opiate or clonidine overdose, administer a narcotic antagonist. The recommended dosage for naloxone is 0.01 to 0.1 milligram/kg IV every 2 minutes until the desired effect is achieved or a total dose of 2 milligrams has been given. Any dose, if successful, may be repeated as necessary to maintain narcotic reversal. Flumazenil (Mazicon), a benzodiazepine antagonist, may be used for pure benzodiazepine ingestion in an otherwise healthy child. The dose is 0.01 milligram/kg IV, with cardiac monitoring established.
 
 
 
== Disposition ==
 
== See Also ==
 
== Source ==
 
<br/><br/>
 
[[Category:WikEM]] <br/>

Latest revision as of 23:05, 20 March 2026

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]

Evaluation

  • Labs
    • Glucose, CBC, chem, UA, CSF, LFT, utox, VBG, BAL, thyroid, Calcium (ionized)
  • ECG
  • Neuroimaging
  • XR
  • UA

Management

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

External Links

References

  1. ↑ Source APLS page 182, 5th ed.
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