Altered Level of Consciousness in Children

Aka: Altered Level of Consciousness in Children, Pediatric Altered Mental Status, Pediatric ALOC

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II. Definitions

  1. Altered Level of Consciousness (Altered Mental Status)
    1. Spectrum of a changed sensorium from confusion and Delirium to lethargy to coma

III. Precautions

  1. Altered Mental Status is mode difficult to evaluate in young children
  2. Presentations in children
    1. Behavior change (e.g. "tantrum")
    2. Inconsolable Crying in Infants
    3. Decreased oral intake
    4. Somnolence

IV. History

  1. See Altered Level of Consciousness
  2. See AMPLE History
  3. Acute or chronic
  4. Preceding events
    1. Seizure
    2. Fever
    3. Headache
    4. Trauma
    5. Toxin Ingestion
      1. See Unknown Ingestion
      2. Ask about substance taken (or suspected to have been taken
      3. Ask about the total amount taken
      4. Ask if this was an intentional Overdose
  5. Neurologic Deficits
    1. Global
      1. Hypoglycemia
      2. Toxin Ingestion
      3. Encephalopathy
      4. CNS Infection (Encephalitis, Meningitis)
      5. Sepsis
    2. Focal
      1. Intracranial Hemorrhage
      2. CNS Mass
      3. Cerebrovascular Accident
  6. Past Medical History
    1. Diabetes Mellitus
    2. Sickle Cell Anemia
    3. Congenital Heart Disease
    4. Inborn Errors of Metabolism
    5. Surgery History (e.g. Ventriculoperitoneal Shunt)

V. Exam

  1. Perform complete physical exam
  2. Obtain full Vital Signs (as well as telemetry)
  3. Neurologic Exam focus areas
    1. See Complete Neurologic Exam
    2. Glasgow Coma Scale (GCS)
    3. Pupil Exam
      1. Pupillary Light Reflex
      2. Pupil Constriction and Pupil Dilation
    4. Evaluate for signs of Brainstem Herniation (e.g. Cushing Response)
  4. Toxicology Exam
    1. See Toxin Induced Vital Sign Changes
    2. See Toxin Induced Skin Changes
    3. See Toxin Induced Neurologic Changes
    4. See Toxin Induced Odors
    5. See Eye Examination Signs of Chemical Dependency

VI. Causes

  1. See Altered Level of Consciousness Causes
  2. Closed Head Injury
    1. See Closed Head Injury
    2. See Mild Head Injury
    3. See Moderate Head Injury
    4. See Severe Head Injury
    5. More common in children given the proportionally large head
  3. Neurovascular Events
    1. See Pediatric Cerebral Hemorrhage
    2. Cerebral Arteriovenous Malformations (CNS AV Malformations)
      1. Most common cause of spontaneous non-Traumatic Intracranial Hemorrhage in children
      2. High risk for recurrent Hemorrhage, each episode increasing morbidity and mortality
    3. Cerebral Aneurysm
      1. Cerebral Aneurysm is less common than AV Malformations in children
      2. Presents with severe Headache, Vomiting, focal neurologic deficits and Altered Mental Status
    4. Cerebrovascular Accident
      1. See Cerebrovascular Accident in Children
      2. Rare in children, outside Sickle Cell Anemia, Congenital Heart Disease and cancer
    5. Central Venous Thrombosis
      1. May present as an infectious complication (e.g. Otitis Media, Acute Sinusitis)
      2. May present with focal neurologic deficit, Seizure (age <4 years), Headache (older children)
    6. Cavernous Hemangioma
      1. Cerebral venous lesion with risk of Intracranial Hemorrhage
      2. Subacute, slowly progressive symptoms (e.g. Headache, Vomiting)
  4. Severe Infection
    1. Precautions
      1. Consider in Hypothermia or fever
    2. Sepsis
      1. See Newborn Sepsis
      2. See Sepsis in Children
      3. Typical sources include Pneumonia, Urinary Tract Infection, intraabdominal infection or CNS Infection
      4. Fever and Rash may help localize source
    3. Meningitis or Encephalitis
      1. May present with Vomiting, Diarrhea, poor feeeding, irritability, lethargy, Seizures, nuchal ridgity, bulging Fontanelle
    4. Intracranial Abscess
      1. Consider in fever with focal neurologic deficits
      2. Higher risk in Congenital Heart Disease, Bacterial Endocarditis, Lung Abscess, esophageal procedures
      3. Subdural Abscess (Subdural Empyema) is spread of Sinusitis or Mastoiditis in more than half of cases
  5. Seizures
    1. See Seizure Disorder
    2. See Unprovoked Seizure in Children
    3. See Febrile Seizure
    4. Consider differential diagnosis in atypical presentations or prolonged postictal period
      1. Closed Head Injury
      2. CNS Infection
      3. Electrolyte disturbance
      4. Inborn Errors of Metabolism
  6. Metabolic Abnormalities
    1. Diabetic Ketoacidosis
      1. See Diabetic Ketoacidosis
      2. See Diabetic Ketoacidosis Management in Children
      3. New Diabetes Mellitus presentations are often non-specific (e.g. irritability, somnolent)
      4. Younger children may lack history of Polyuria, polydipsia, weight loss
      5. Observe for periodic breathing (e.g. Kussmaul Breathing) or Hyperventilation
    2. Inborn Errors of Metabolism
      1. See Inborn Errors of Metabolism
      2. See Crashing Neonate
      3. Consider in young children (age <2 years) with Vomiting, poor feeding, irritability, lethargy, Seizures, Tachypnea
      4. Higher risk children may have Failure to Thrive or Developmental Delay, or history of BRUE
    3. Hypoglycemia
      1. See Hypoglycemia causes
      2. May present with irritability, decreased feeding, Seizures
      3. Causes include Sepsis, Inborn Errors of Metabolism, Diarrhea, Hypothyroidism, Hypopituitarism, Adrenal Insufficiency
      4. Consider Toxin Ingestion (Beta Blockers, Alcohol, Salicylates)
    4. Congenital Adrenal Hyperplasia
      1. May present with Adrenal Insufficiency (Hypoglycemia, Hyponatremia, Hyperkalemia) with salt-wasting (Sodium loss)
      2. Girls are typically diagnosed at birth due to Ambiguous Genitalia, with delayed diagnosis in boys
    5. Hyponatremia
      1. See Hyponatremia
      2. Consider in Dehydration (recent Vomiting or Diarrhea), or Fluid Overload (e.g. Congenital Heart Disease, Kidney disease)
      3. Consider SIADH (e.g. Pneumonia, Bacterial Meningitis, Rocky Mountain Spotted Fever)
    6. Hypocalcemia
      1. Hypoparathyroidism may present with Hypocalcemia and Fatigue, lethargy, Muscle spasms or Seizures
    7. Hyperthyroidism
      1. Neonatal Thyrotoxicosis (rare)
        1. Consider in newborns of mothers with Hyperthyroidism
      2. Thyroid Storm
        1. Presents with Hyperthyroidism and fever, Hypertension and possible Congestive Heart Failure
        2. Rare in young children, but may be seen in teenagers
  7. Toxin Ingestion
    1. See Unknown Ingestion
    2. See Accidental Poisoning Causes
    3. See Medication Dosing Errors in Children
    4. Consider toxindromes
      1. Anticholinergic Toxicity
        1. Presents with Mydriasis, Dry Mouth, Tachycardia and possible Delirium, Seizures
        2. Contrast with Sympathomimetic Toxicity which is similar, but with diaphoresis
      2. Cannabinoid or Synthetic Cannabinoid ingestion
        1. Pediatric ingestions have become more common, with greater toxicity due to concentrated products
        2. Presents with lethargy and Ataxia, as well as hypotonia, Tachycardia, hypoventilation
      3. Carbon Monoxide Poisoning
        1. Presents with irritability, Vomiting, Headache and lethargy
        2. Consider co-toxicity, cyanide Poisoning, after Smoke Inhalation from structure fire
      4. Opioid Overdose
        1. Presents with hypoventilation, somnolent or unresponsive and Miosis
      5. Salicylate Overdose
        1. Presents with Tachypnea, Vomiting, Diarrhea, Tinnitus, fever, Tachycardia

VII. Labs

  1. See Altered Level of Consciousness
  2. Bedside Glucose
  3. Complete Blood Count
  4. Comprehensive Metabolic Panel
    1. Serum Electrolytes
    2. Liver Function Tests
    3. Renal Function Tests
  5. Urinalysis
  6. Venous Blood Gas
  7. Toxicologic Screening
    1. Alcohol Level
    2. Acetaminophen Level
    3. Salicylate Level
    4. Urine Drug Screen
  8. Additional Testing as indicated
    1. Cultures (Blood Culture, Urine Culture)
    2. Lumbar Puncture with CNS Culture

VIII. Imaging

  1. See Altered Level of Consciousness
  2. Chest XRay
  3. Head Imaging (CT Head or MRI Brain)
    1. See Head Injury CT Indications in Children
    2. Consider CTA or MRA (and CTV or MRV) in suspected neurovascular abnormalities (see causes above)
    3. Head imaging is also indicated in some cases when CNS Infection is suspected
      1. Immunocompromised
      2. Focal Neurologic deficit
      3. Papilledema or other signs of Increased Intracranial Pressure
      4. Known CNS condition
      5. Cerebral Abscess or Subdural Empyema suspected
    4. Indications to perform head imaging before Lumbar Puncture
      1. Coma or other severely decreased mental status
      2. Papilledema or other signs of Increased Intracranial Pressure
      3. Focal neurologic deficit
      4. Ventriculoperitoneal Shunt
      5. Recent neurosurgery
      6. Recent Head Trauma

IX. Management: Stabilization

  1. See Altered Level of Consciousness
  2. ABC Management first
    1. Stabilize airway, breathing and circulation first
    2. Endotracheal Intubation for GCS 8 or less (or other Advanced Airway Indications)
      1. See Advanced Airway in Children
  3. Empiric reversal agents
    1. See agent protocols below
    2. Consider DONT Mnemonic empiric management (Dextrose, Oxygen, Naloxone, Thiamine)
    3. Correct Hypoglycemia
    4. Correct Electrolyte abnormalities (e.g. Hyponatremia)
    5. Correct Hypoxia
    6. Correct Hypovolemia
  4. Trauma-related management for Closed Head Injury
    1. See Trauma Evaluation
    2. See Management of Severe Head Injury
    3. See Status Epilepticus
    4. See Pediatric Trauma
    5. See Increased Intracranial Pressure in Closed Head Injury
    6. Consider Nonaccidental Trauma
    7. Consider neurosurgery Consultation
    8. C-Spine Immobilization
    9. See Mild Head Injury for disposition guidance
  5. Neurovascular Conditions
    1. Consult pediatric neurology or neurosurgery
    2. See Intracranial Hemorrhage
    3. See Cerebrovascular Accident in Children
    4. See Cerebrovascular Accident in Sickle Cell Anemia
  6. Infectious Conditions
    1. See Newborn Sepsis
    2. See Sepsis in Children
    3. See Bacterial Meningitis Management
    4. See Brain Abscess
    5. Initiate fluid Resuscitation (starting with 20 to 30 ml/kg)
    6. Obtain cultures, evaluate for infection source and administer broad spectrum, empiric IV antibiotics
    7. Administer Vasopressors (e.g. Norepinephrine) as needed
    8. Consult pediatric neurosurgery in cases of Brain Abscess or empyema
  7. Seizures
    1. See Status Epilepticus
    2. See Seizure Disorder
    3. See Unprovoked Seizure in Children
    4. See Febrile Seizure
      1. Distinguish simple Febrile Seizure from complex Febrile Seizure
  8. Metabolic Abnormalities
    1. See Diabetic Ketoacidosis Management in Children
    2. Hypoglycemia
      1. See Hypoglycemia Management
      2. Obtain bedside Glucose in every case of Altered Mental Status
      3. Consider Hypoglycemia causes (e.g. Sepsis, Inborn Errors of Metabolism, Toxin Ingestion)
      4. Monitor Serum Glucose frequently until Glucose consistently >70 mg/dl
      5. Consider Adrenal Insufficiency, Congenital Adrenal Hyperplasia or Hypopituitarism
        1. Adrenal Insufficiency is associated with Hypoglycemia, Hyponatremia and Hyperkalemia
        2. Treated with Hydrocortisone, Intravenous Fluids, Hypoglycemia and elecrolyte management
    3. Inborn Errors of Metabolism (includes Neonatal Metabolic Emergency)
      1. Consult endocrinology
      2. Obtain labs as above, in addition to Serum Ammonia >100 to 200 mmol/L, Uric Acid, Lactic Acid
      3. Patients may have Hypoglycemia, increased ammonia level, Metabolic Acidosis
      4. Empiric D10W is often given in suspected cases while evaluating and stabilizing
    4. Electrolyte abnormalities
      1. Identify and treat underlying cause (e.g. infection)
      2. See Hyponatremia Management
      3. See Potassium Replacement (in Hypokalemia)
      4. See Calcium Replacement (in Hypocalcemia)
    5. Hyperthyroidism
      1. See Thyroid Storm
      2. See Hyperthyroidism
  9. Toxin Ingestion
    1. See Unknown Ingestion
    2. Manage specific toxin exposures
      1. See Anticholinergic Toxicity
      2. See Cannabinoid
      3. See Synthetic Cannabinoid ingestion
      4. See Salicylate Overdose
      5. See Opioid Overdose
        1. Administer Naloxone 0.1 mg/kg (max 2 mg/dose)
        2. Consider Naloxone infusion for ingestion of long acting Opioid (e.g. Methadone)
        3. Administer supportive care (e.g. PPV), and intubate if needed
      6. See Carbon Monoxide Poisoning
        1. Apply non-rebreather with facemask at 100% FIO2 until Carbon Monoxide level is resulted (if suspected)

X. References

  1. Newsome, Long and Sanghani (2022) Crit Dec Emerg Med 36(3): 15-24
  2. Orman and Chang in Herbert (2017) EM:Rap 17(4): 8-9
  3. (2016) CALS, 14th ed, 1:52-3
  4. Herbert et al. in Herbert (2014) EM:Rap 14(10): 11-2
  5. Herbert et al. in Herbert (2014) EM:Rap 14(11): 10-12
  6. Veauthier (2021) Am Fam Physician 104(5): 461-70 [PubMed]

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