Pediatrics Grand Rounds University of Texas Health Science

15 July 2011 Center at San Antonio

Child Neurology Altered Mental Status and Coma

Objectives Altered Mental Status

Recognize most common causes of Altered This condition is not a disease, but a condition
Mental Status in Childhood caused by a variety of diseases or clinical states, it
is a medical emergency to understand the cause

Address management and understand when

to transport the child

Altered Mental Status Altered Mental Status

Examination of the child

1) ABCs

2) Neurologic Exam
Cranial Nerves
Deep Tendon Reflexes
Sensory
Motor
? Cerebellar
Mental Status

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Altered Mental Status Altered Mental Status

Neurologic Exam Neurologic Exam

Cranial Nerves Cranial Nerves

Eye movements Pupillary light reflex

Dolls Eyes
Cold Water Calorics

Altered Mental Status Altered Mental Status

Neurologic Exam Neurologic Exam

Cranial Nerves Cranial Nerves

Corneal Sensation Gag

Altered Mental Status Altered Mental Status

Motor Exam
Neurologic Exam
Cranial Nerves

Respiratory Drive

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Arousal Function
Reticular activating system
Midbrain
Pons
Medulla

Altered States of
Consciousness
Definitions:

Lethargy Difficult to arouse Encephalopathy diffuse disorder

Altered state of consciousness
Altered cognition or personality
Obtundation Responsive to stimuli other than pain Seizures
Encephalitis
Stupor Responsive only to pain Encephalopathy plus CSF pleocytosis

Coma Unresponsive to pain

The treehole mosquito (Aedes triseriatus) transmits the

virus that causes La Crosse encephalitis

Motor
Response Example Score
Commands Follows simple commands 6
Localizes Pulls examiner's hand away Eye-Opening
Eye- .
Pain when pinched 5 Spontaneous Opens eyes on own 4
Withdraws Pulls a part of body away when Opens eyes when asked to
from Pain pinched 4 To Voice in a loud voice 3
Abnormal Flexes body inappropriately to To Pain Opens eyes when pinched 2
Flexion pain 3 No Response Does not open eyes 1
Body becomes rigid in an
Abnormal extended position when
Extension examiner pinches him 2
No Response Has no motor response to pinch 1

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Verbal Response
Carries on a conversation Altered Mental Status
correctly and tells examiner
where he is, who he is, and
Oriented the month and year 5
Confused Seems confused or
Conversation disoriented 4
Talks so examiner can
understand him but makes
Inappropriate Words no sense 3
Makes sounds that
Sounds examiner cannot understand 2
No Response Makes no noise 1

Causes of Lethargy, Stupor and Coma: Evaluation of Lethargy, Stupor and Coma:

Intracranial Hematoma Intracranial Hematoma CT Scan

Cerebral Edema Cerebral Edema CT Scan
Postictal State
Hypoxic Brain Injury Postictal State Hx of Sz, EEG
Hypoglycemia Hypoxic Brain Injury Hx of Hypoxic event
Toxin Ingestion
Meningitis/Encephalitis Hypoglycemia Chemistries

Toxin Ingestion Tox Screen/ Medication levels

Meningitis/Encephalitis CBC/ LP

Delirium
Acute confusional state with impaired
alertness
Delirium Alerting functions
Overworking or underworking
Difficulty focusing, shifting or sustaining attention

Formal definition includes:

Fluctuating confusion
Disturbed sleep wake cycle

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Pathophysiology Clinical Features

4 general causes Onset is within days
3 general variants of activity and alertness
1. Primary intracranial disease
1. Hypoalert-hypoactive
2. Systemic disease affecting CNS 2. Hyperalert-hyperactive
3. Mixed
3. Exogenous toxins May cycle rapidly between hyperactive and
hypoactive.

4. Drug withdrawal

Clinical Features Diagnosis

Altered sleep wake cycles
Sundowning
Tremor, tachycardia, diaphoresis, outbursts,
delusions, hallucinations may occur
Diagnosis primarily by history
Physical exam to look for causes
Additional testing to identify a cause
Labs: CMP, CBC, UA
+/- lumbar puncture
Radiology: CXR and head CT
MMSE

Treatment Treatment
Treat the underlying cause Sedation
Infections: pneumonia, UTI, meningitis, sepsis Haloperidol
Metabolic: hypoglycemia, electrolytes, hepatic, Lorazepam
thyroid disorders, ETOH, or drugs
Neurologic: CVA, TIA, seizure, intracranial Confinement or restraints as appropriate
hemorrhage or mass
Cardiopulmonary: CHF, MI, PE, hypoxia
Drug related: Narcotics, sedatives, muscle Admit unless rapidly reversible cause is
relaxants, antiemetics, digoxin identified

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Coma
State of reduced alertness and responsiveness
from which you cannot be aroused
Coma
Glasgow Coma Scale
Motor, verbal, eye opening

Pathophysiology Mass Lesions Causing Coma

Global Secondary to compression of the brainstem
Hypoglycemia, hypoxia
Primarily uncal vs. central
CNS
Brainstem disease
Bilateral cortical disease
Unilateral should not present as coma

Uncal herniation Central Herniation

Medial temporal lobe compresses brainstem Progressive loss of consciousness
Decreased responsiveness going into a coma
Ipsilateral pupil dilated and nonreactive Decorticate posturing

Irregular respirations

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Pediatrics Grand Rounds University of Texas Health Science
15 July 2011 Center at San Antonio

Clinical Features Diagnosis

Coma secondary to hemispheric hemorrhage Stabilization diagnosis and treatment overlap
may still have localizing features ABCs
Lab,+/- LP
Pupillary, muscle, and cranial nerve exam to CT head
determine central vs. focal Examination
Focal vs. diffuse
Pupillary response generally preserved in toxic
metabolic coma

Specific Issues Treatment

C-spine immobilization if trauma suspected Reverse identifiable causes
Glucose
Pediatric coma commonly ingestion, infection,
Naloxone
or abuse
If signs or history of opioid use

Seizures Flumazenil
Coma s/p seizure activity Only recommended if history of benzo use not as
electromechanical dissociation of the brain and body routine.

Special Situations:

Brain Death vs. No hope of Meaningful

Recovery