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Altered mental status in children is characterized by the failure to respond to verbal or physical stimulation in a manner appropriate to the child’s developmental level. The ED incidence of altered mental status in children varies widely depending on the type of institution reporting, the patient population served, and the specific definition of altered mental status used.1,2 Children with altered mental status require simultaneous stabilization, diagnosis, and treatment. The objectives of treatment are to sustain life and prevent irreversible central nervous system damage. Once the patient is resuscitated, the next objective is to establish the cause and stop disease progression.

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The spectrum of alteration of mental status ranges from confusion or delirium (disorders in perception) to lethargy, stupor, and coma (states of decreased awareness). A lethargic child has decreased awareness of self and the environment. In the ED, this translates to decreased eye contact with family members and health care personnel. A stuporous child has decreased eye contact, decreased motor activity, and unintelligible vocalization. Stuporous patients can be aroused with vigorous noxious stimulation. Comatose patients are unresponsive and cannot be aroused by verbal or physical stimulation, such as phlebotomy, arterial catheterization, or lumbar puncture.3

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Irrespective of the cause, altered mental status indicates depression of the cerebral cortex or localized abnormalities of the ascending reticular activating system. Both cerebral cortices must be affected to cause altered mental status. Typical causes of bilateral cortical impairment are toxic and metabolic states that deprive the brain of normal substrates. Altered mental status also can be produced through dysfunction of the reticular activating system that is housed in the brainstem and midbrain. This system connects cranial nerve nuclei and extends from the brainstem to the thalamus. The reticular activating system governs respirations, cardiovascular functions, many aspects of homeostasis, and daily wake and sleep cycles. Any abrupt interruption or selective destruction of the reticular activating system may result in altered mental status.4

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The pathologic conditions that affect awareness and arousal can be divided into three broad pathologic categories: supratentorial mass lesions, subtentorial mass lesions, and metabolic encephalopathy.5

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Supratentorial mass lesions compress the brainstem and/or diencephalon. Signs and symptoms of this type of lesion include focal motor abnormalities, which are often present from the onset of the altered level of consciousness. The progression of neurologic dysfunction is from rostral to caudal, with sequential failure of midbrain, pontine, and medullary functions. When compromise due to supratentorial lesions is present, the fast component of nystagmus is in a direction away from a cold stimulus during caloric testing.

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Subtentorial mass lesions lead to reticular activating system dysfunction, in which prompt loss of consciousness is generally the rule. Cranial nerve abnormalities are frequent, and abnormal respiratory patterns, such as Cheyne-Stokes respiration, neurogenic hyperventilation, and ataxic breathing, are common. With brainstem injury, asymmetric and/or fixed pupils are found. No eye movements occur despite cold water irrigation of both auditory canals.

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