Clinical Features

Two individuals are needed to manage a pediatric patient with AMS. One individual should act as historian to perform a methodical and comprehensive interview. The key questions that must be explored concern prodromal events leading to the change in consciousness, recent illnesses, the likelihood of an infectious exposure or exposure to intoxicants, and the likelihood of trauma, including abuse.14 The historian should make inquiries regarding antecedent fever, headache, head tilt, abdominal pain, vomiting, diarrhea, gait disturbance, seizures, drug ingestion, palpitations, weakness, hematuria, weight loss, and rash. For infants and young children with AMS, developmental milestones should be pursued. The past medical history, immunization history, and family history are important in children of all ages. The clinician should be alert for any inappropriate responses or inconsistencies and delays in seeking care that may arouse the suspicion of child abuse. Although it may be possible to obtain a history quickly, in order to be thorough and pay attention to detail, one physician must be dedicated to obtaining the history while the second physician manages the resuscitation.

One should proceed with a general examination only after cardiac and cerebral resuscitation. The objectives of the examination are to identify occult infection, trauma, toxicity, or metabolic disease.46 The neurologic examination should document the child's response to sensory input, motor activity, pupillary reactivity, oculovestibular reflexes, and respiratory pattern. Although several coma scales have been published,89 the most simplified and functional in an emergency setting is the AVPU scale. This is a descriptive tool in which A means "alert," V means "responsive to verbal stimuli," P means "responsive to painful stimuli," and U means "unresponsive."

Following a targeted history and a focused examination, the treating physician should anticipate and observe changes in the patient's status that may indicate improvement or deterioration. An additional task of the physician who attends the patient is to make an operational, if not specific, diagnosis of AMS.

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