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1. Is there a history of witnessed or suspected trauma?

2. Does patient have fever?

3. What is the probability of poisoning, ingestion, or overdose?

4. What are the associated symptoms (eg, headache, seizures, diplopia, weakness, vomiting, bloody diarrhea, abdominal pain)?

5. Is there a contributing past medical history (eg, seizure disorder, brain tumor, ventricular shunt, sickle cell disease, metabolic disorder, diabetes, liver disease, renal failure)?

III. Differential Diagnosis. Altered mental status may have structural, medical, or functional causes. Common etiologies according to age are presented in Table I-2.

A. Structural Causes. Tend to result in asymmetric or focal neurologic findings, particularly affecting pupillary response, extraocular movements, and motor response to pain.

1. Trauma. Typically involves a shearing mechanism (diffuse axonal injury) from rapid deceleration. Shearing forces can rupture blood vessels and result in epidural, subdural, or intra-parenchymal hemorrhage. When suspected mechanism of injury does not fit extent of patient's injuries, always consider inflicted trauma or child abuse.

2. Tumor. Symptoms such as headache, vomiting, or focal neurologic deficit are typically present for weeks to months. Altered mental status can result from seizures, intracranial hypertension, or cerebral edema.

3. Cerebrovascular event. Hemorrhagic and ischemic strokes occur with the same frequency in children. A ruptured arteriovenous malformation is the most common cause of hemorrhagic





Inborn errors of metabolism Infection

Metabolic alterations Seizure


Abuse or trauma Infection Intussusception Seizure






Trauma stroke in children. Ischemic and thrombotic strokes occur most commonly in children with sickle cell disease and congenital heart defects; less commonly in children with hypercoagulable states, metabolic disorders, vasculitis, and other vascular abnormalities. Patients with hemorrhagic strokes tend to present with altered mental status and headache whereas those with ischemic strokes present with focal neurologic deficits.

4. Hydrocephalus. Infants present with increased head circumference, thin scalp with distended veins, and bulging fontanel. Other nonspecific symptoms such as irritability, poor feeding, and vomiting may be present. Sunset sign (decreased upward gaze), which results from weakness of cranial nerve VI, may be present.

a. Communicating. Occurs when CSF is not absorbed by arachnoid villi as a result of infection or hemorrhage.

b. Noncommunicating. Occurs when congenital malformations or acquired tumors block normal CSF circulation.

5. Infection. Contiguous spread of middle ear or sinus infection can lead to an epidural abscess in older children and adolescents.

B. Medical Causes. Include any process that decreases delivery of substrate to the brain. Pupils are generally equal and reactive, and neurologic exam is nonfocal.

1. Infection. Fever, irritability, lethargy, and vomiting are common presenting symptoms.

a. Meningitis. Infants and young children often have nonspecific symptoms. Headache and neck stiffness may not be present in children younger than 2 years of age.

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