1. Narcotic overdose. If suspected, administer naloxone.
2. Head injury or focal neurologic finding. Obtain CT scan of head and neurosurgical consultation.
3. Metabolic alterations. Correct metabolic and electrolyte abnormalities and acidosis.
Altered mental status
' Airway (maintain patency) 1 Breathing (100% O2) ' Circulation (IV placement)
History or suspicion of head injury-^ Immobilize C-spine
Bedside glucose determination
Focal neurologic finding History of head trauma
Controlled hyperventilation, Yes mannitol, emergent head CT scan, neurosurgical consultation
If miosis, consider naloxone
Suspected structural etiology
Suspected medical etiology
Figure I-1. Management algorithm for a child with altered mental status. (C-spine = cervical spine; GCS = Glasgow Coma Scale; HUS = hemolytic uremic syndrome; ICP = intracranial pressure; LP = lumbar puncture.)
Poisoning or overdose. If suspected, administer charcoal (if indicated and ingestion occurred within 1 hour) and antidote if available.
Fever, CNS infection, or sepsis. Perform a lumbar puncture if patient is stable and does not have signs of increased intracranial pressure. Administer antibiotics if considering bacterial CNS disease or sepsis.
Hyperammonemia. Consider workup for metabolic disorder. Guaiac-positive stools. Evaluate for intussusception or HUS.
VI. Problem Case Diagnosis. The 9-year-old boy was breathing spontaneously with a rate of 40 breaths/min and appeared dehydrated on admission to the emergency department. He was given 100% oxygen via face mask, and IV access was obtained. Rapid bedside blood glucose determination showed a critically high value, and subsequent venous blood gas and serum electrolyte determination showed diabetic ketoacidosis. Patient was rehydrated and started on an insulin infusion.
VII. Teaching Pearl: Question. What clues help differentiate a functional from an organic cause of altered mental status?
VIII. Teaching Pearl: Answer. Organic causes of altered mental status need to be excluded first. However, patients feigning unresponsive-ness will have increased heart rate with painful stimuli, may resist eye opening, and will avoid hitting the face when their hand is allowed to drop to it.
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