A 7-year-old previously healthy girl presents to the ED with fever, neck pain, and increased sleepiness since the previous day. The patient’s mother reports that she has had a nonproductive cough for the past 2 days, with associated nasal congestion and runny nose. She also notes that the girl has had a decreased appetite since the previous day, a temperature of 38.5ºC, neck pain, and has been lethargic. The patient’s mother does not report a rash, and the remainder of the review of systems is negative. On examination, the patient is found to be sleepy and slowly arousable to commands. The girl's pupils are equal, 4 mm, and react briskly to light. She winces with extension of her knees and has reflex flexion of her hips and knees upon passive neck flexion. As you discuss the likely diagnosis with the girl's mother, you start to think about the management of this patient: What laboratory studies should be sent? Which medications should be administered? Are imaging studies indicated at this time?
A 14-year-old previously healthy adolescent boy presents to the ED after being found by his parents in his room, unconscious. Hours prior to being found, the patient was reportedly with his friends at the movies and was in his usual state of health. His parents deny any fever, nausea, vomiting, or known trauma. The physical examination is notable for a well-developed male who is lethargic and makes only incomprehensible sounds. His physical examination is otherwise normal. What are the likely etiologies for this patient’s altered mental status? What are some interventions that can be initiated to prevent morbidity?
A 9-year-old girl with propionic acidemia presents to the ED with 3 days of nonbloody, nonbilious emesis, and 1 day of lethargy and increased work of breathing. She has not been able to eat anything as a result of the vomiting. Her parents report that she woke up this morning looking very tired and sleepy, which prompted them to bring her to the hospital. The parents deny any fever, diarrhea, or preceding upper respiratory symptoms. The physical examination is notable for disorientation to person, place, and date. She has dry mucous membranes and a capillary refill time of 2 seconds. Her vital signs are as follows: temperature, 37ºC; heart rate, 150 beats/min; respiratory rate, 28 breaths/min; and blood pressure, 80/40 mm Hg. You know that you’ll need to hydrate this patient, but which intravenous fluids should you use? At what rate should the intravenous fluids run? What other interventions will be needed?
The term altered level of consciousness (ALOC) can be used to describe a spectrum of disorders that includes clouding of consciousness, confusion, lethargy, obtundation, stupor, or coma.1,2 In young children, ALOC may manifest as fussiness or irritability. Due to the varying degrees of altered consciousness, it is important for the emergency clinician to be familiar with the various terms that can be used to describe a patient’s clinical status, and to recognize that there is much similarity among them.
ALOC can be induced by traumatic or nontraumatic mechanisms. In a British epidemiological study completed in 2001, the incidence of nontraumatic coma in children aged < 16 years was reported to be 30.8 per 100,000 per year, with a noted increased incidence in children aged < 1 year (160 per 100,000 per year).3 In other hospital-based studies, nontraumatic coma was noted to be more common in children aged < 6 years than in older children.4
Etiologies for ALOC can be numerous, but a broad differential can be reviewed quickly with the aid of mnemonics such as MOVESTUPID, which is adapted from adult emergency medicine practice. (See Table 1.) Other commonly used mnemonics include AEIOU TIPS (alcohol/acidosis, epilepsy, insulin, overdose, uremia, trauma, infection, psychosis, stroke) or DPT OPV HIB MMR (dehydration, poisoning, trauma; occult trauma, postictal/ postanoxia, ventriculoperitoneal shunt; hypoxia/ hyperthermia, intussusception, brain masses; meningitis/encephalitis, metabolic, Reye syndrome/rare causes).5 Of these etiologies, the most common cause of nontraumatic coma is an infectious etiology.3,6
This month’s issue of Pediatric Emergency Medicine Practice will review a broad differential diagnosis for pediatric patients who present to the emergency department (ED) with ALOC, as well as present the initial workup and interventions to stabilize such patients.
An online literature search was performed using the PubMed and Ovid MEDLINE® databases with the search terms altered level of consciousness, acute loss of consciousness, altered mental status, and coma. For literature searches using the search terms altered mental status and coma, fields were limited to the age group between 0 and 18 years of age and articles written in the English language. A total of 381 articles were reviewed. In addition, individual literature searches were performed for each of the differential diagnoses listed in Table 2 and reviewed for relevance to ALOC or altered mental status. The Cochrane Database of Systematic Reviews was searched using the key terms altered level of consciousness, acute loss of consciousness, and altered mental status, but no reviews were found; using the key term coma, 31 reviews were identified.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.
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Points to keep in mind:
Why to Use
The Glasgow Coma Scale (GCS) is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
Daniel Runde, MD
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
The Modified Glasgow Coma Scale (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS Scale score) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
In the acute care setting, the GCS has been shown to have highly variable reproducibility and inter-rater reliability (ie, 56% among neurosurgeons in 1 study, 38% among emergency department physicians in another). In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
In summary, the Modified Glasgow Coma Scale provides an almost universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score results in information loss and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale, as in the SMS, can perform as well as the GCS and is significantly less complicated. However, the SMS may be less informative in patients with lesser injuries.
Sir Graham Teasdale, MBBS, FRCP
Joo Lee Song, MD; Vincent J. Wang, MD, MHA
January 2, 2017
February 2, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 0.5 Pharmacology CME credits
Upon completion of this article you should be able to:
Date of Original Release: January 1, 2016. Date of most recent review: December 15, 2016. Termination date: January 1, 2019.
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