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

2. 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

3. 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

4. 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)

5. 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

6. GCS in a child

7. AVPU scoring system

8. Signs of herniation

9. 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

10. 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

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

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

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

14. General treatments options

15. Maintain open airway
Sniffing position
Jaw thrust

16. 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

17. Coma in MANA

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