Altered mental status (peds)

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  • Both cerebral cortices must be affected to cause altered mental status

Pediatric GCS[1][2]

Eye Opening Verbal Motor
6: Normal spontaneous movement
5: Smiles, coos, babbles 5: Withdraws to touch
4: Opens eyes spontaneously 4: Irritable, crying (but consolable) 4: Withdraws to pain
3: Opens eyes to speech only 3:Inconsolable crying or crying only in response to pain 3: Abnormal flexion to pain (Decorticate response)
2: Opens eyes to pain only 2: Moans in response to pain 2: Abnormal extension to pain (Decerebrate response)
1: Does not open eyes 1: No response 1: No response


  • For Motor score 4, pain is defined flat, fingernail pressure (often performed with the barrel of a pencil).
  • For Motor scores 2 and 3, pain is defined by pressing hard on the supraorbital notch. If this unsuccessful, sternal pressure may also be attempted.

Clinical Features

Differential Diagnosis

A  Alcohol O  Opiates
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 Thermal extremes
  Hypertensive encephalopathy I  Infection
  Reye syndrome   Meningitis
  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
  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 Shunt malfunction


  • Labs
    • Glucose, CBC, chem, UA, CSF, LFT, utox, VBG, BAL, thyroid, Calcium (ionized)
  • ECG
  • Neuroimaging
  • XR
  • Urine


  • Immobilize cervical spine for suspected trauma
  • Fluid resuscitation 20 mL/kg x3 as needed; start pressors thereafter
  • Antibiotics for sepsis or meningitis (consider viral it patient is toxic)
  • Naloxone for opiate or clonidine overdose (0.01-0.1mg/kg IV q2 min)
  • Glucose for 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

External Links


  1. Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric glasgow coma scale in children with blunt head trauma. Acad Emerg Med. 2005 Sep;12(9):814-9.
  2. James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986 Jan;15(1):16-22.