View source for Altered mental status (peds)

{{Peds top}} [[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 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==
{| class="wikitable"
|- 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="13" | '''A'''&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" | [[Alcohol]] 
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | '''O'''&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" | [[Opioids]]
|- 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" | [[Acid-base disorders|Acid-base]] and [[inborn errors of metabolism|metabolic disorders]]
| 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="3" | '''U'''&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" | [[Uremia]]
|- 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;[[Diabetes mellitus]]
| 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;Chronic [[renal failure]]
|- 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;[[Dehydration (peds)|Dehydration]] 
| 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;[[Hemolytic-uremic syndrome]]
|- 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;[[Hypercapnia]] 
| 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="10" | '''T'''&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" | [[Trauma]]
|- 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;[[Hepatic failure]]
| 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;General [[trauma (peds)|trauma]] with [[hypovolemia]]
|- 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;[[Hypoxia]]
| 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;[[Head injury]]
|- 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;[[Inborn errors of metabolism]]
| 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;[[Intracranial mass|Mass lesion]]
|- 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" | [[Arrhythmia]] and cardiogenic causes 
| 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;Cerebral edema
|- 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;[[Ventricular fibrillation]] 
| 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;[[Cerebrovascular accident]]
|- 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;Adams-Stokes attack 
| 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;[[Electric shock]]
|- 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;[[Aortic stenosis]]
| 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;[[Decompression sickness]]
|- 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" | [[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; 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" | [[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" | [[Hyperthermia]], [[hypothermia]]
|- 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;[[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" | [[Infection]]
|- 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;[[Meningitis]]
|- 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="2" | &nbsp;&nbsp;[[Pediatric shock]]|Hemorrhagic shock]] and encephalopathy 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;[[Encephalitis]]
|- 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;[[Brain abscess]]
|- 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;Postimmunization 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;[[Visceral larva migrans]]
|- 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;Disseminated encephalomyelitis 
| 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;Severe [[sepsis (peds)|systemic infection]]
|- 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="2" | &nbsp;&nbsp;[[Human immunodeficiency virus]] 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" | Intracerebral vascular disorders
|- 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;[[Subarachnoid hemorrhage]]
|- 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" | Endocrinopathy 
| 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;[[Venous thrombosis]]
|- 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;[[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; 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" rowspan="2" | &nbsp;&nbsp;[[ICH|Intracerebral]] or intraventricular hemorrhage
|- 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;[[Thyrotoxicity]]
|- 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;[[Cushing 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;Cerebral embolus
|- 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;[[Pheochromocytoma]] 
| 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;Acute infantile hemiplegia
|- 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;Hepatic [[porphyria]]s 
| 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;Acute confusional [[Migraine headache|migraine]]
|- 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" | [[Electrolyte abnormalities]] 
| 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;[[Moyamoya]] malformation
|- 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;[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" | [[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; 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" | [[Insulin]] 
| class="font12" style="font-size: 12px; margin: 0px 0px 9px; color: rgb(51,51,51); line-height: 17px" valign="top" align="left" bgcolor="#ffffff" | Psychogenic unresponsiveness
|- 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;[[Hypoglycemia]] 
| 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="4" | '''S'''&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" | [[Seizure]]
|- 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;Ketotic [[hypoglycemia (peds)|hypoglycemia]] 
| 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="3" | [[VP shunt malfunction]]
|}

===Additional<ref>Source APLS page 182, 5th ed.</ref>===
*[[Sympathomimetics]]/[[cocaine]]
*[[Anticholinergics]]
*[[Arsenic]]
*[[LSD]]
*[[PCP]]
*[[Phenothiazines]]
*[[Salicylates]]
*[[Theophylline]]
*[[levothyroxine|Thyroxine]]

==Evaluation==
*Labs 
**Glucose, CBC, chem, UA, CSF, LFT, utox, VBG, BAL, thyroid, Calcium (ionized)
*[[ECG]] 
*Neuroimaging
*XR
*[[UA]]

==Management==
*Immobilize cervical spine for suspected trauma 
*[[Fluid resuscitation]] 20 mL/kg x3 as needed; start pressors thereafter 
*[[pediatric antibiotics|Antibiotics]] for [[sepsis]] or [[meningitis]] (consider [[antiviral]] it patient is toxic)
*[[Naloxone]] for [[opioid toxicity|opioid]] or [[clonidine toxicity|clonidine overdose]] (0.01-0.1mg/kg IV q2 min)  
*[[dextrose|Glucose]] for [[hypoglycemia (peds)|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==
*[http://pemplaybook.org/podcast/altered-mental-status-in-children/ Pediatric Emergency Playbook Podcast: Altered Mental Status in Children]

==References==
<references/>

[[Category:Pediatrics]] [[Category:Neurology]]