3. Cerebrovascular event (hemorrhagic and ischemic strokes occur with same frequency in children).

4. Hydrocephalus (communicating or noncommunicating).

5. Infection (eg, epidural abscess, usually in older children and adolescents from contiguous spread of middle ear or sinus infection).

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. (See Chapter 6, Altered Mental Status, III, B, p. 28, for additional discussion.)

1. Infection (eg, meningitis, encephalitis, subdural empyema, sepsis).

2. Poisoning or overdose. See Table I-3, p. 29, for examples of common drugs that may cause coma. Because many drugs and toxins are not detectable on serum and urine screening tests, a high index of suspicion should be maintained. Some ingested substances cause a specific constellation of signs (toxidrome), which aids in diagnosis and management (see Table I-4, p. 30).

3. Metabolic alterations (eg, hyperglycemia or hypoglycemia, electrolyte abnormalities, buildup of waste or metabolic products due to renal or hepatic failure, or inborn errors of metabolism).

4. Hemolytic uremic syndrome (eg, secondary to infection with E coli O157:H7).

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