Altered Mental Status

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Chapter 6 Altered Mental Status

Douglas S. Nelson, MD, FAAP, FACEP

1 How can altered mental status present in an infant?

It may present as a combination of crying, irritability, poor feeding, or sleeping more or less than usual.

2 What clues can I use to determine whether altered mental status is due to a toxic ingestion?

Suspect a toxic ingestion when no history of trauma is present, abnormal consciousness was of sudden onset, the patient was unsupervised, the patient appears to have a chaotic home situation, or the patient has a history of previous ingestions.

Dobson JV, Webb SA: Life-threatening pediatric poisonings. J S C Med Assoc 100:327–332, 2004.

3 What scales are in use to quantify altered mental status? Why should I use them?

The level of consciousness of a neurologically impaired patient may initially be evaluated by using a simple AVPU scale, representing four major levels of alertness: alert, responsive to verbal stimuli, responsive to painful stimuli, and unresponsive.

A more widely used measurement of consciousness is the Glasgow Coma Scale (GCS). Patients are graded on three areas of neurologic function: eye opening, motor responses, and verbal responsiveness. These numeric scores are added to determine the GCS score. A GCS score of 3 is the minimum score possible and represents complete unresponsiveness, while a GCS score of 15 is assigned to fully alert patients. Details of the scale are listed below:

1 Eye opening

image Spontaneous: 4
image To speech: 3
image To pain: 2
image None: 1

2 Best motor response

image Obeys verbal command: 6
image Localizes to painful stimulus: 5
image Flexion withdrawal: 4
image Flexion decorticate: 3
image Extension decerebrate: 2
image No response: 1

3 Best verbal response*

image Oriented; converses: 5
image Disoriented; converses: 4
image Inappropriate words: 3
image Incomprehensible sounds: 2
image No response: 1

There are several good reasons to use a standard quantifiable mental status scale. It allows evaluation of a patient’s changing neurologic status over time and the recording of this information in the medical record. The effect of medical interventions may then be more easily assessed. The use of accepted scoring systems also facilitates communication with consultants, such as neurologists and neurosurgeons.

Nelson DS: Coma and altered level of consciousness. In Fleisher G, Ludwig S (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 201–212.

KEY POINTS: CLUES TO TOXIC INGESTION IN A CHILD WITH ALTERED MENTAL STATUS

1 No trauma

2 Sudden onset of symptoms

3 Lack of supervision of patient

4 Chaotic home

5 Previous ingestions

4 Which toxins not detected on most drug screens can cause abnormal mental status?

The following toxins are associated with altered mental status and miosis: clonidine, chloral hydrate, organophosphates, and tetrahydrozoline. Mydriasis and altered mental status are found with other toxins: carbon monoxide, cyanide, methemoglobinemia, LSD, and γ-hydroxybutyrate.

5 What do the letters DPT, OPV, HIB, and MMR stand for?

Although these represent abbreviations for several childhood immunizations, the letters also comprise a mnemonic to recall common causes of abnormal mental status.

D = Dehydration O = Occult trauma
P = Poisoning P = Postictal or Postanoxia
T = Trauma V = VP shunt problem
H = Hypoxia or Hyperthermia M = Meningitis or encephalitis
I = Intussusception M = Metabolic
B = Brain mass R = Reye’s syndrome, other Rarities
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