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c. Subdural empyem a. May occur secondary to meningitis or from direct extension of otitis media or sinusitis. Seizures occur in two thirds of patients.

d. Sepsis. Can cause shock from circulating inflammatory mediators.

2. Poisoning or overdose. Poisoning or overdose from many substances can cause altered mental status (Table I-3). Because many drugs and toxins are not detectable on serum and urine screening tests, a high index of suspicion must be maintained. Some ingested substances cause a specific constellation of signs (toxidrome), which aids in diagnosis and management. Table I-4 summarizes common toxidromes.

3. Seizure. Children can present in the postictal state without a witnessed seizure. Seizures may be followed by a transient period of paralysis (Todd paralysis) usually affecting one side of the body, which may lead to a false suspicion of a structural etiology.

4. Metabolic alterations. Hyperglycemia or hypoglycemia, electrolyte (Na+ or Ca2+) abnormalities, and inborn errors of metabolism can cause altered mental status.

5. Intussusception. Occasionally, patients with intussusception can present with profound lethargy (presumably due to release of cytokines from the entrapped bowel wall) with little or no history of abdominal complaints.

TABLE I-3. SUBSTANCES THAT CAN CAUSE POISONING OR OVERDOSE ASSOCIATED WITH COMA

Amphetamines

Anticholinergics

Barbiturates

Benzodiazepines

Carbamazepine

Carbon monoxide

Clonidine

Cocaine

Ethanol

Gamma hydroxybutyrate (GHB)

Haloperidol

Narcotics

Phencyclidine (PCP) Phenothiazines Phenytoin Salicylates

Selective serotonin reuptake inhibitors (SSRIs) Tricyclic antidepressants

TABLE I-4. TOXIDROMES

Toxidrome

Mental Status

Pulse

RR

BP

Pupil Size

Skin

Temp

Specific Management

Opioid

Depressed

Low

Low

Low

Pinpoint

Normal

i

Naloxone

Sedative hypnotic

Depressed

Low

Low

Low

Normal

Normal

Normal

Flumazenil (controversial)

Sympathomimetic

Agitated

High

Normal

High

Î

Diaphoretic

î

Benzodiazepines

Cholinergic

Agitated

High or low

Normal

High or low

Î

Diaphoretic

Normal

Atropine, pralidoxime

Anticholinergic

Agitated or delirium

High

High or low

High or low

Î

Dry

î

Physostigmine, benzodi-

azepines t = increased; I = decreased; BP = blood pressure; RR = respiratory rate; temp = temperature.

azepines t = increased; I = decreased; BP = blood pressure; RR = respiratory rate; temp = temperature.

6. Hemolytic uremic syndrome (HUS). HUS secondary to infection with E coli O157:H7 can cause lethargy, seizures, or coma from uremia.

C. Functional Cause. Consider functional cause, especially when all organic causes have been ruled out.

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