Altered mental status (peds): Difference between revisions
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''This page is for <u>pediatric</u> altered mental status. See [[altered mental status]] for the adult page.''
{{Peds top}} [[altered mental status]]
==Background==
==Background==
*Both cerebral cortices must be affected to cause altered mental status  
*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==
==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.


==Differential Diagnosis==
==Differential Diagnosis==
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|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Pericardial tamponade]]
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Pericardial tamponade]]
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | Tumor
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | [[brain tumor|Tumor]]
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="18" | '''E'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="18" | '''E'''&nbsp;  
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| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Hypertensive encephalopathy]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Hypertensive encephalopathy]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="16" | '''I'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="16" | '''I'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | Infection
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | [[Infection]]
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Reye syndrome]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Reye syndrome]]  
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|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Addison's disease]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Addison's disease]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;Arterial thrombosis
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Arterial thrombosis]]
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Congenital adrenal hyperplasia]]  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[[Congenital adrenal hyperplasia]]  
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| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[Na<sup>+</sup>], [Ca<sup>2+</sup>], [Mg<sup>2+</sup>], PO<sub>4</sub><br>&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | &nbsp;&nbsp;[Na<sup>+</sup>], [Ca<sup>2+</sup>], [Mg<sup>2+</sup>], PO<sub>4</sub><br>&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="2" | '''P'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="2" | '''P'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | Poisoning
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | [[toxicity|Poisoning]]
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
|- class="font12" style="font-size: 12px; margin: 0px 0px 9px; line-height: 17px"
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="5" | '''I'''&nbsp;  
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" rowspan="5" | '''I'''&nbsp;  
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*[[Salicylates]]
*[[Salicylates]]
*[[Theophylline]]
*[[Theophylline]]
*[[Thyroxine]]
*[[levothyroxine|Thyroxine]]


==Evaluation==
==Evaluation==
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*Neuroimaging
*Neuroimaging
*XR
*XR
*Urine
*[[UA]]


==Management==
==Management==
*Immobilize cervical spine for suspected trauma  
*Immobilize cervical spine for suspected trauma  
*Fluid resuscitation 20 mL/kg x3 as needed; start pressors thereafter  
*[[Fluid resuscitation]] 20 mL/kg x3 as needed; start pressors thereafter  
*Antibiotics for [[sepsis]] or [[meningitis]] (consider viral it patient is toxic)
*[[pediatric antibiotics|Antibiotics]] for [[sepsis]] or [[meningitis]] (consider [[antiviral]] it patient is toxic)
*Naloxone for opiate or clonidine overdose (0.01-0.1mg/kg IV q2 min)   
*[[Naloxone]] for [[opioid toxicity|opioid]] or [[clonidine toxicity|clonidine overdose]] (0.01-0.1mg/kg IV q2 min)   
*Glucose for hypoglycemia (2 mL/kg of 25% dextrose)  
*[[dextrose|Glucose]] for [[hypoglycemia (peds)|hypoglycemia]] (2 mL/kg of 25% dextrose)  
*Avoid sodium bicarbonate for metabolic acidosis unless pH <7.0  
*''Avoid'' [[sodium bicarbonate]] for [[metabolic acidosis]] unless pH <7.0  
*Control [[seizures]]
*Control [[seizures]]
*Prevent [[hypothermia]], treat hyperthermia
*Prevent [[hypothermia]], treat [[hyperthermia]]


==See Also==
==See Also==

Latest revision as of 22:48, 28 November 2019

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

See Also

External Links

References

  1. ↑ Source APLS page 182, 5th ed.
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