Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

Recognize most common causes of Altered Mental Status in Childhood

Address management and understand when to transport the child

This condition is not a disease, but a condition caused by a variety of diseases or clinical states, it is a medical emergency to understand the cause

Examination of the child1) ABC’s

2) Neurologic ExamCranial NervesDeep Tendon ReflexesSensoryMotor?  CerebellarMental Status

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

Neurologic ExamCranial Nerves

Eye movementsDoll’s EyesCold Water Calorics

Neurologic ExamCranial Nerves

Pupillary light reflex

Neurologic ExamCranial Nerves

Corneal Sensation

Neurologic ExamCranial Nerves

Gag

Neurologic ExamCranial Nerves

Respiratory Drive

Motor Exam

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

Reticular activating systemMidbrainPonsMedulla

Definitions:

Lethargy – Difficult to arouse

Obtundation – Responsive to stimuli other than pain

Stupor – Responsive only to pain

Coma – Unresponsive to pain

Encephalopathy – diffuse disorder

Altered state of consciousnessAltered cognition or personalitySeizures

EncephalitisEncephalopathy plus CSF pleocytosis

The treehole mosquito (Aedes triseriatus) transmits 

the virus that causes La Crosse encephalitis

Motor Response Example ScoreCommands Follows simple commands 6Localizes Pain

Pulls examiner's hand away when pinched 5

Withdraws from Pain

Pulls a part of body away when pinched 4

Abnormal Flexion

Flexes body inappropriately to pain 3

Abnormal Extension

Body becomes rigid in an extended position when examiner pinches him 2

No Response Has no motor response to pinch 1

Eye-Opening .Spontaneous Opens eyes on own 4

To VoiceOpens eyes when asked to in a loud voice 3

To Pain Opens eyes when pinched 2No Response Does not open eyes 1

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

Verbal Response

Oriented

Carries on a conversation correctly and tells examiner where he is, who he is, and the month and year 5

Confused Conversation

Seems confused or disoriented 4

Inappropriate Words

Talks so examiner can understand him but makes no sense 3

SoundsMakes sounds that examiner cannot understand 2

No Response Makes no noise 1

Causes of Lethargy, Stupor and Coma:

Intracranial HematomaCerebral EdemaPostictal StateHypoxic Brain InjuryHypoglycemiaToxin IngestionMeningitis/Encephalitis

Evaluation of Lethargy, Stupor and Coma:

Intracranial Hematoma CT Scan

Cerebral Edema CT Scan

Postictal State Hx of Sz, EEG

Hypoxic Brain Injury Hx of Hypoxic event

Hypoglycemia Chemistries

Toxin Ingestion Tox Screen/ Medication levels 

Meningitis/Encephalitis CBC/ LP

Acute confusional state with impaired alertnessAlerting functions

Overworking or underworkingDifficulty focusing, shifting or sustaining attention

Formal definition includes:Fluctuating confusionDisturbed sleep wake cycle

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

4 general causes

1. Primary intracranial disease

2. Systemic disease affecting CNS

3. Exogenous toxins

4. Drug withdrawal

Onset is within days3 general variants of activity and alertness

1. Hypoalert‐hypoactive2. Hyperalert‐hyperactive3. Mixed

– May cycle rapidly between hyperactive and hypoactive.

Altered sleep wake cycles“Sundowning”Tremor, tachycardia, diaphoresis, outbursts, delusions, hallucinations may occur

Diagnosis primarily by historyPhysical exam to look for causesAdditional testing to identify a cause

Labs: CMP, CBC, UA+/‐ lumbar puncture

Radiology: CXR and head CTMMSE

Treat the underlying causeInfections: pneumonia, UTI, meningitis, sepsisMetabolic: hypoglycemia, electrolytes, hepatic, thyroid disorders, ETOH, or drugsNeurologic: CVA, TIA, seizure, intracranial hemorrhage or massCardiopulmonary: CHF, MI, PE, hypoxiaDrug related: Narcotics, sedatives, muscle relaxants, antiemetics, digoxin

SedationHaloperidolLorazepam

Confinement or restraints as appropriate

Admit unless rapidly reversible cause is identified

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

State of reduced alertness and responsiveness from which you cannot be aroused

Glasgow Coma ScaleMotor, verbal, eye opening

GlobalHypoglycemia, hypoxia

CNSBrainstem diseaseBilateral cortical disease

Unilateral should not present as coma

Secondary to compression of the brainstem

Primarily uncal vs. central

Medial temporal lobe compresses brainstemDecreased responsiveness going into a comaIpsilateral pupil dilated and nonreactive

Progressive loss of consciousness

Decorticate posturing

Irregular respirations

Pediatrics Grand Rounds 9 July 2010

University of Texas Health Science Center at San Antonio

Localized vs. generalizedCerebral blood flow constant with MAP of 50‐100 mm of HgCPP = MAP – ICPCushing reflex of hypertension and bradycardia

Coma secondary to hemispheric hemorrhage may still have localizing featuresPupillary, muscle, and cranial nerve exam to determine central vs. focalPupillary response generally preserved in toxic metabolic coma

Stabilization diagnosis and treatment overlapABC’sLab,+/‐ LPCT headExamination

Focal vs. diffuse

C‐spine immobilization if trauma suspectedPediatric coma commonly ingestion, infection, or abuseSeizures

Coma s/p seizure activity“electromechanical dissociation of the brain and body”

Reverse identifiable causesGlucose

Thiamine prior if alcoholicNaloxone

If signs or history of opioid useFlumazenil

Only recommended if history of benzo use not as routine.