Altered states of consciousness

An altered level of consciousness is an important clinical entity in pediatrics and carries the potential for significant morbidity and mortality. The clinician must assess the level of consciousness rapidly as well as determine likely causes. Structural or medical causes usually can be differentiated through a focused history and physical examination. Asymmetric neurologic findings such as a dilated and fixed pupil, dyscongugate extraocular movements, and asymmetric motor findings suggest brainstem dysfunction as a result of a structural lesion; slowly progressive but symmetric neurologic findings usually result from a medical disorder. Specific neurologic findings associated with elevated intracranial pressure are seen in both central and uncal herniation. Disorders of metabolism, liver, kidneys, lungs, or heart as well as toxic exposure are common medical causes for alteration of consciousness. After initial assessment and stabilization, management centers on determining the specific diagnosis and continuing supportive care.