Altered mental status (peds)

Background

• Both cerebral cortices must be affected to cause altered mental status

Pediatric GCS

Eye Opening	Verbal	Motor
		6: Normal spontaneous movement
	5: Smiles, coos, babbles	5: Withdraws to touch
4: Opens eyes spontaneously	4: Irritable, crying (but consolable)	4: Withdraws to pain
3: Opens eyes to speech only	3:Inconsolable crying or crying only in response to pain	3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only	2: Moans in response to pain	2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes	1: No response	1: No response

Note:

• For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
• For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Differential Diagnosis

A	Alcohol	O	Opiates
	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		Thermal extremes
	Hypertensive encephalopathy	I	Infection
	Reye syndrome		Meningitis
	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		Shunt malfunction

Evaluation

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

Treatment

• Immobilize cervical spine for suspected trauma
• Fluid resuscitation 20 mL/kg x3 as needed; start pressors thereafter
• Antibiotics for sepsis or meningitis (consider viral it patient is toxic)
• Naloxone for opiate 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

External Links

• Pediatric Emergency Playbook Podcast: Altered Mental Status in Children

References

Authors

Jordan Swartz, Ross Donaldson, Tim Horeczko, Daniel Ostermayer, Jonathan Osgood, Marissa Camilon, Claire, Neil Young