Altered mental status in children Dr. Minoo Saeidi Assisstant professor of pediatrics Isfahan university of medical sciences

Definition Failure to respond to verbal or physical stimulation appropriate to the childs developmental level This condition is critical So it needs stabilization, diagnosis and treatment simultaneously Ascending reticular system in brain stem Cerebral cortex Long term morbidities due to hypoxia

Clinical features Confusion, not alert to time and place and persons Delirium, abnormal perception, it is not common in children Lethargy, aroused with load voice but go to sleep immediately Stupor, aroused with noxious stimulation, decreased motor activity, abnormal vocalization Coma, can not be aroused with any stimulation like as phlebotomy Symptoms of increased intracranial pressure, herniation Special features due to the underlying cause

Important historical elements Prodromal events (recent trauma, infections, illnesses) Medications available at home Vaccinations Developmental status Social environment (abuse, neglect) Family history Associated symptoms (fever, weight loss, vomiting, diarrhea, gait changes, abdominal pain, seizure or abnormal movement, weakness, palpitation, head tilt, rash, hematuria)

Physical exam General physical exam (PR, RR, T, BP) Neurological exam (determine level of consciousness, pupillary reflex, pattern of respiration, motor activity) Signs of abuse Signs of intoxication Expose the child Check blood glucose Monitoring

GCS in a child

AVPU scoring system

Signs of herniation

Diagnosis Use this mnemonic: AEIOU TIPS A: Alcohol, Acid base and metabolic, Arrhythmia and cardiac causes E: Encephalopathy, Endocrinology, Electrolytes I: Insulin, Intussusception O: Opiates, Oxygen U: Uremia T: Trauma, Tumors, Thermal I: Infections, Intracerebral vascular events P: Psychogenic, Poisoning S: Seizure

Routine diagnostic tests Glucose Na, K, Ca, Cl, HCO3, BUN, Cr ABG Serum ammonia AST, ALT Blood and urine screen for toxins CSF analysis (viral PCR is optional) Neuroimaging (CT, MRI, MRV, MRA) EEG Orders

Secondary tests Orders Serum lead level Serum lactate, pyruvate Serum amino acids Urine organic acids Acylcarnitine profile Orders

Common causes in childhood Toxins Infections Head trauma Hypoxia/Ischemia (near drowning, cardiac arrest) Seizure (post ictal phase, subclinical status epilepticus)

Transient & recurrent LOC Seizure Migraine (basilar or confusional migraine, agitation, ataxia, cortical blindness, vertigo, headache) Syncope (neurocardiogenic, arrhythmia, obstructive cardiomyopathy) Hypoglycemia Hyperammonemia

General treatments options

Maintain open airway Sniffing position Jaw thrust

Discharge & follow up Transient and reversible causes in emergency department Diseases specific discharge instruction An evaluation within 24 hours of discharge PICU admission in prolonged and/or critical cases

Coma in MANA

References Nelson essentials chapter 184 Tintinallis emergency medicine chapter 137 MANA 1395