Altered Mental Status

Altered Mental Status
BY
DR MOHAMED ABDULHAY AHMED
LECTURER OF PAEDIATRICS AND PAEDIATRIC NEUROLOGY
FACULTY OF MEDICINE – HELWAN UNIVERSITY
• BACKGROUND;
✓ Awareness depends on continuous communication between the brainstem’s ascending fibers of reticular
activating System and the cerebral cortex.
✓ Delirium is an alternation in consciousness that falls along the spectrum from normal awareness to coma.
✓ Standardized language is necessary to properly diagnose and treat the grades of alterations in consciousness
such as lethargy, confusion, obtundation, stupor, and coma, are listed in the following table.
Terms Definitions
Lethargy Conscious but looks sleepy with slow reactions
Confusion Conscious but disoriented to time, place & persons
Obtundation Unconscious but respond to stimulation other than pain
Stupor Unconscious but respond to only to pain

Coma Unconscious and cannot be aroused even by painful stimuli
• CAUSES OF ALTERED MENTAL STATUS IN CHILDREN;
Alteration of consciousness results from brain dysfunction, that in turn results from inadequate interaction
between the cerebral hemispheres and reticular activating systems of brainstem. This could be either due to;
✓ Intracranial causes;
- Infectious; meningitis or encephalitis
- Traumatic; direct head trauma or indirect e.g shaken baby syndrome
- Vascular; thromboembolic or haemorrhagic stroke
- Epileptic; post-ictal state or status epilepticus
- Neoplatic; primary brain tumors or metastasis
✓ Extracranial causes;
- Toxic; poisoning by drugs e.g barbiturates or by chemicals e.g carbon monoxide/organophosphorous
- Metabolic; e.g hypoglycemia/hyperglycemia, hyponatremia/hypernatremia, hypo or hyperthermia, uremia,
hepatic encephalopathy
- Hypoxic; may be due to either hypoxic hypoxia e.g Respiratory Failure / hypoxic ischemic e.g sever
dehydration or cardiac arrest / hypoxic anaemic e.g sever acute haemolysis
• APPROACH TO MANAGEMENT OF A CASE OF ALTERED MENTAL STATUS IN CHILDREN;
1) Proper positioning of the patient
2) Emergency management; ABC(Air patency, breathing, circulation access).
3) Assess vital signs.
4) Assess the level of consciousness(Glasgow coma scale)
5)Assess level of brain dysfunction(whether cortical or brainstem). This could be assessed by
- Motor response
- Pupillary size & reaction
- Pattern of brathing
Brainstem coma Hemispheric coma

Level of conciousness Looks asleep Looks awake
Motor response Looks unnatural e.g Looks often natural i.e
decerebrate or flaccid comfortable & respond to
external stimuli
But,sometimes look
decorticate in case of
thalamic lesion
Pupillary size & reaction Tends to be abnormal e.g Tends to show normal
midposition or pinpoint response to light
Respiratory pattern Apneustic or ataxic Normal or chyne-stokes
6) Signs of increased intracranial tension;
• Bulging fontanel or split cranial sutures in an infant
• Severe vomiting that is exquisitely positional (i.e., strongly provoked by the transition from lying
to sitting).
• sever irritability or headache .
• 3rd or 6th nerve palsy; anisocoria, ptosis, diploplia
• persistent downward deviation of both eyes (tonic downward gaze deviation)
• Cushing triad (bradycardia, respiratory Irregularities, and hypertension)
• papilledema(Papilledema is usually absent in children with an open fontanel.)
7) Signs of lateralization:(may be difficult to elicit in coma) e.g focal convulsions, asymmetric
motor response and asymmetric brain stem reflexes→ focal brain lesion.
8) Signs of meningeal irritation
9) History taking
It should be taken rapidely in attempt to detect the underlying cause e.g
A) Onset of coma;
-Sudden; stroke or trauma
-Subacute; CNS infection
-Gradual; Tumor
B) specific event just before the coma
-Fever → CNS infection / pontine or subarachnoid Hge / DKA / addisonian crisis or hyperthyroid crisis / salicylate
poisoning / heat stroke
-Trauma → concussion, contusion or intracranial haemorrhage
-Headache, vomiting and blurring of vision →sudden ↑I.C.T as in subarachnoid hge ( mostly dt A-V. Malformation)
-Drug intake or insecticide
-Polyurea, polydipsia &vomiting → DKA
-In newborn : DCL , POI +/- frequent convulsions → inborn error of metabolism or sepsis. (Periods Of Clinical Interest)
C) history of previous diseases as
-H. Of diabetes → DKA
-H. Of hypertension → hypertensive E.
-H. Of epileptic →post ictal state or status epilepticus.
-H. Of chronic renal disease →uremia
-H. Of chronic liver disease → hepatic encephalopathy-
-H. Of severe pulm or heart disease or anemia →hyoxic ischemic
10) Examination;
It should be done rapidely in attempt to detect the underlying cause as well ,with special focusing on eye
examination(window of the brain); as following;
WORK UP
-Blood samples for(ABG + RBG + CBC, electrolytes ,kidney functions, liver functions + drug screening)
-CT brain
-EEG monitoring
-CSF(in case of CNS infection or increased intracranial tension)
-Sepsis screen(if suspected)
-Metabolic screen(if suspected)
MANAGEMENT
Comatose child should be admitted to ICU to receive the followings;
1)Stabilization of vital signs(ABC) as mentioned before
2)Baseline records that should be repeated every hour(vital signs, fluid chart & GCS)
3)Supportive measures e.g
Care of skin, care of breathing, care of the eye, care of nutrition , Care of bladder, etc…..
4)Specific therapy for the underlying cause

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Altered Mental Status

Obtundation Unconscious but respond to stimulation other than pain

Stupor Unconscious but respond to only to pain

Brainstem coma Hemispheric coma

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