Pediatric emergency medicine trisk 0374 0374
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or a cerebral hemorrhage will present with an abrupt change in mental status and
agitation that worsens over a period of minutes to hours. These patients may also
be intoxicated, making the evaluation challenging. Careful assessment of vital
signs, and, in this case, head imaging and toxicologic screening will assist in
making the correct diagnosis. Other medical conditions, such as thyroid disease,
diabetes mellitus, and electrolyte imbalances, will present sub-acutely. These
disorders are usually preceded by medication changes or by a period of weeks to
months of symptoms such as weight change, hair loss, diarrhea or vomiting, or
fatigue. A patient with a chronic condition such as cardiac or renal disease can
present with agitation during a period of acute worsening of their underlying
illness. It is therefore critically important to obtain an accurate medical history.
A special consideration in pediatrics, especially in the preverbal,
developmentally delayed, or intellectually disabled child, is assessment of pain.
These children may appear agitated or demonstrate other behavioral changes to
reflect physical discomfort. A careful history from the primary caregiver,
complete physical examination, and a broad differential are important when
evaluating these children. Nonaccidental injury should always be considered,
especially in the child with intellectual disability, as these children have been
shown to be at higher risk.
Toxicologic Ingestion or Withdrawal
Acute ingestion of certain toxicologic substances, or in the case of a chronic user,
withdrawal from a substance, commonly leads to agitation and may lead to
psychosis ( Table 13.4 ). Frequently, drug intoxication presents with the acute
onset of disordered thinking with visual hallucinations. A history of drug abuse
and the availability of toxic substances are other important historical facts.
Intoxication with alcohol, sedatives, antidepressants, anticholinergic agents, and
heavy metals can be life threatening. Withdrawal syndrome in patients habituated
to alcohol or sedative–hypnotic agents may likewise result in severe agitation,
psychosis, seizure, and death (see Chapter 102 Toxicologic Emergencies ).
Delirium
Delirium is broadly defined as acute, fluctuating global cerebral dysfunction due
to a medical condition. The presentation can be quite variable, but a core feature
is a disturbance in consciousness with a decreased ability to focus, sustain, or
shift attention ( Table 13.5 ). While many delirious patients may be agitated or
suffering from hallucinations, others can appear hypoactive, quiet, and
withdrawn. Irritability, mood fluctuation, and anxiety are common findings in
