What is the initial workup and management for a child presenting with confusion?

Initial Workup and Management for a Child Presenting with Confusion

The initial workup for a child presenting with confusion should include a comprehensive assessment for potential medical, neurological, psychiatric, and traumatic causes, with immediate stabilization of vital functions and targeted diagnostic testing based on clinical presentation.

Initial Assessment and Stabilization

Primary Survey (ABCs)

• Ensure airway patency and adequate oxygenation
• Assess breathing pattern and provide supplemental oxygen if needed
• Check circulatory status (heart rate, blood pressure, perfusion)
• Assess level of consciousness using age-appropriate scales (AVPU or pediatric Glasgow Coma Scale)
• Check blood glucose immediately (hypoglycemia is a common, reversible cause)

Immediate Life-Threatening Conditions to Rule Out

• Hypoglycemia: Check blood glucose immediately
• Seizure activity: Assess for ongoing subtle seizures
• Increased intracranial pressure: Check for pupillary abnormalities, posturing, hypertension with bradycardia
• Toxic ingestion: Look for toxidromes (pupil size, vital sign patterns)
• Trauma: Examine for signs of head injury
• Infection: Assess for signs of meningitis or encephalitis

Focused History

Key Historical Elements

• Onset and progression of confusion (sudden vs. gradual)
• Associated symptoms (fever, headache, vomiting, seizures)
• Recent trauma or falls
• Medication use or potential toxic exposures
• Recent illnesses or infections
• Developmental history and baseline cognitive function
• Past medical history, especially neurological, metabolic, or psychiatric conditions
• Family history of metabolic or neurological disorders

Physical Examination

Targeted Physical Examination

• Vital signs including temperature (fever may indicate infection)
• Complete neurological examination including:
  • Pupillary responses
  • Motor function and coordination
  • Reflexes
  • Cranial nerve function
  • Signs of meningeal irritation (nuchal rigidity, Kernig's sign, Brudzinski's sign)
• Skin examination for rashes (meningococcemia, Rocky Mountain spotted fever)
• Signs of trauma or abuse
• Fundoscopic examination for papilledema

Initial Diagnostic Workup

Laboratory Studies

• Complete blood count with differential
• Basic metabolic panel (electrolytes, glucose, BUN, creatinine)
• Liver function tests
• Toxicology screen (urine and blood)
• Blood culture (if infection suspected)
• Arterial blood gas (if respiratory compromise or metabolic derangement suspected)
• Ammonia level (if hepatic encephalopathy or metabolic disorder suspected)

Imaging and Additional Studies

• Neuroimaging: CT scan of the head without contrast as initial study if:
  • Focal neurological findings
  • History of trauma
  • Suspected increased intracranial pressure
  • Persistent altered mental status
• Consider MRI brain for more detailed evaluation if CT is negative but clinical suspicion remains high
• Lumbar puncture if meningitis/encephalitis suspected (after neuroimaging if increased ICP is a concern)
• EEG if seizure activity is suspected

Management Based on Etiology

Seizure Management

• For active seizures, follow pediatric seizure protocol 1, 2, 3:
  • Lorazepam 0.1 mg/kg IV/IO (maximum 4 mg) over 2-5 minutes
  • If seizures continue after 5-10 minutes, repeat lorazepam dose
  • For refractory seizures, consider phenytoin 18 mg/kg IV loading dose over 20 minutes
  • For status epilepticus, prepare for rapid sequence intubation and ICU admission

Infection

• If meningitis/encephalitis suspected, start empiric antibiotics (ceftriaxone) and acyclovir after obtaining appropriate cultures
• Antipyretics for fever

Metabolic Derangements

• Correct electrolyte abnormalities
• For hypoglycemia: D10W 2-4 mL/kg IV bolus
• For suspected inborn errors of metabolism: consult metabolic specialist

Toxic Ingestion

• Specific antidotes based on identified toxin
• Supportive care and enhanced elimination as appropriate

Pediatric Mental Health Considerations

Mental Health Assessment

• Assess for psychiatric causes if medical causes are ruled out 1
• Screen for trauma history, as emotional trauma can cause neurochemical and structural brain changes 1
• Consider delirium assessment using validated tools like the Cornell Assessment Pediatric Delirium tool (CAP-D) 1

Behavioral Management

• For agitation or behavioral disturbances, use non-pharmacological approaches first:
  • Calm environment with familiar caregivers
  • Minimize stimulation
  • Clear communication
  • Reorientation techniques

Disposition

Criteria for Hospital Admission

• Persistent altered mental status
• Abnormal vital signs
• Abnormal laboratory or imaging findings
• Uncertain diagnosis requiring observation
• Inadequate home supervision or follow-up

ICU Transfer Criteria 1

• Deteriorating neurological status
• Need for airway management or ventilatory support
• Persistent seizures or status epilepticus
• Hemodynamic instability

Common Pitfalls to Avoid

• Failing to check blood glucose immediately
• Delaying antibiotics when infection is suspected
• Missing non-convulsive status epilepticus
• Overlooking toxic ingestions in toddlers and adolescents
• Attributing confusion to psychiatric causes before ruling out medical etiologies
• Neglecting to consider trauma, including non-accidental trauma
• Failing to recognize delirium, which is often underdiagnosed in children 1

Remember that pediatric confusion can present as part of various conditions and requires a systematic approach to diagnosis and management, with careful attention to age-specific considerations and potential causes.