Atypical Altered Mental Status in a Toddler

Abstract

A 2-year-old girl presented with 2 days of altered mental status (AMS). Symptoms included increased sleepiness, irritability, aggression, decreased oral intake and urine output, as well as weakness and refusal to walk. Her history was negative for fever, cough, rhinorrhea, vomiting, diarrhea, rashes, seizurelike activity, recent head trauma, or other injuries. There were no known sick contacts or recent travels. She did attend day care. The family reported no medications in the home.In triage, she was afebrile with a pulse of 125 beats per minute, respiratory rate of 21 breaths per minute, blood pressure of 103/79, and oxygen saturation of 100% on room air. On examination, the child was sleepy and difficult to arouse. Her neurologic examination was notable for irritability, delayed response to stimuli, ataxia, and a Glasgow Coma Scale of 14. There were no focal neurologic defects appreciated.Question: What are the current recommendations for the evaluation of a child with AMS? DiscussionAMS is defined as a change in a patient' s awareness of self or how a patient interacts with their environment. 1,2 AMS is a complex presenting symptom with a wide range of severity and broad differential that varies by a patient' s age ( Table 1).The basics of emergency management (including airway, breathing, and circulation) should guide any initial evaluation. A clinician must then attempt to distinguish between causes for AMS by using a systematic approach for evaluation and diagnostic testing. The mnemonic VITAMIN C (vascular, infectious, trauma, autoimmune/allergy, metabolic/mass lesion, idiopathic/iatrogenic, neoplasm, and congenital) can be used as a quick reminder of the potential causes of AMS.A thorough history from family members and other sources including neighbors, prehospital personnel, or law enforcement is imperative. 3,4 A complete review of systems, as well as the patient' s past medical history (including previous ingestions, recent medication changes, or propensity for infection or metabolic derangements), are also important in guiding management. Vital signs, particularly fever, can help point to an infectious cause; however, ingestions can also lead to significant vital sign abnormalities. Alterations in respiratory patterns may suggest toxic or metabolic derangements, whereas bradycardia and hypertension may point to increased intracranial pressure. The physical examination must include a complete neurologic examination focusing on