The etiology of altered mental status determines the treatment. Ingestions may necessitate gastric lavage, charcoal administration, forced diuresis, dialysis, or specific antidotes (Chapter 45). Infections are treated with appropriate antibiotics or antiviral agents (Chapter 95). If mental status changes are due to increased ICP, acute medical interventions (osmotic agents, steroids, hyperventilation) must be instituted, emergent neuroimaging performed, and urgent neurosurgical consultation obtained. Structural brain lesions may necessitate medical treatment of increased ICP or surgical excision.
The outcome of altered mental status relates to many variables, including etiology. Intoxication typically carries a good prognosis, whereas hypoxia carries a poor prognosis. Other prognostic factors include the duration of coma and the age of the patient; children have better outcomes than adults. Complete recovery from traumatic coma of several days’ duration is possible in children; however, many survivors of prolonged coma are left in a persistent vegetative state or with severe neuropsychiatric disability.
Transient, Recurrent Depression of Consciousness
Episodic alteration or depression of consciousness with full recovery is usually due to seizure, migraine, syncope, or metabolic abnormality (hypoglycemia). Consciousness can be impaired during seizures or in the postictal state. Nonconvulsive (subclinical) status epilepticus (generalized or focal) can directly impair consciousness and is a common complicating factor for patients with acute neurological disorders (head trauma, meningitis, following convulsive status epilepticus). Some patients may have a prolonged postictal state after an unrecognized seizure.
Basilar artery or confusional migraines can last hours and be accompanied by agitation, ataxia, cortical blindness, vertigo, or cranial nerve palsies. Headache may precede or follow the neurologic signs.
Syncope is one of the most common causes of abrupt, episodic loss of consciousness. Neurocardiogenic syncope, cardiac arrhythmia, or an obstructive cardiomyopathy can cause recurrent episodes of loss of consciousness. Two thirds of children with syncope have irregular, myoclonic movements as they lose consciousness (anoxic seizures), which much be distinguished from epilepsy (unprovoked seizures). Children with unexplained syncope require a complete cardiac examination (Chapter 140).
Metabolic derangements, particularly hypoglycemia, give rise to episodes of lethargy, confusion, seizures, or coma. Several other metabolic disorders cause recurrent bouts of hyperammonemia (Chapter 53). Symptoms include nausea, vomiting, lethargy, confusion, ataxia, hyperventilation, and coma.
Following head injury, children may have immediate depression of consciousness and neurologic deficits or may be completely alert without any immediate signs of neurologic injury. Most serious trauma results from motor vehicle crashes, sports, recreation-related injuries, and violence. Head trauma may result in concussion, posttraumatic intracranial hemorrhage, skull fractures, or cranial nerve or cervical spine injuries. Head injury, or other injuries, with associated retinal hemorrhages in infants and young children should raise the suspicion of abusive head trauma.
Concussion is the process in which traumatic forces on the brain result in the rapid onset of short-lived neurologic impairment that typically resolves spontaneously. Patients may have signs or symptoms in one or more domain: somatic (headache), cognitive (slowed reaction times, feeling like they are in a fog, poor attention), emotional (lability, irritability), sleep
Return to play protocol follows a stepwise progress with each step taking 24 hours. The athlete should continue to the next level if asymptomatic at the current level.
1.
No activity, complete physical and mental rest.
2.
Light aerobic exercise such as walking or stationary cycling; no resistance training.
3.