Acute confusional state in paediatric age - Case Report
Authors: Cordeiro F. , Cartaxo T. , Reis F. , Moniz P. , Alves M. , Bayam C. , Santos V. 
Published: August 2023

Introduction

Acute confusional state (ACS) or delirium is an acute neuropsychiatric syndrome due to
an underlying organic pathological process. Despite its high prevalence, delirium can present
a diagnostic challenge, particularly in paediatric patients. ACS can be defined as sudden
impairment of mental status in a previously healthy child. The impairment varies; it may be
global and severe or very specific and mild, such as impairment of short-term memory in
“transient global amnesia.” The most common causes of ACS in the paediatric population are
high fever, drugs, traumatic brain injury (TBI), and infection and inflammation of the
nervous system. Traumatic brain injury is usually associated with some impairment of
consciousness, although recovery can vary depending on the severity of the trauma.

Objectives

The aim of this work is to revisit the diagnostic approach and management of ACS
associated with traumatic brain injury in the paediatric population.

Methods

Case report of an acute confusional state, secondary to a TBI and a non-systematic
review of the literature.

Results

A 17-year-old female was admitted to the emergency department after being injured in a
car accident. She was drowsy but easily awakened. She was conscious and partially oriented in
time and space. She had amnesia for the episode. She spoke fluently and coherently but was
hesitant regarding the hours before the accident, which was probably due to memory
impairment. She exhibited sporadic hetero-aggressive behavior during the first few hours of
the examination. She had no other thought or perceptual disorders. Head CT scan showed “a
thin collection of blood from the frontal interhemispheric area and a discrete subarachnoid
sulcal frontobasal hemorrhage, with no other significant changes.” Toxicology tests were
positive for THC, cocaine, and MDMD and negative for blood alcohol. A forensic medical
examination was required. After 48 hours of vigilance and improvement, she was discharged
with a booked re-evaluation within a week. At the second evaluation, her mother described a
change in her usual behavior with disorientation, drowsiness, difficulty managing daily life,
and memory impairment. She had persecutory delusions regarding the physicians and was very
agitated. She was admitted to a child and adolescent psychiatric hospital for further
evaluation and stabilization. After 72 hours of inpatient stay, she fully recovered,
receiving low-dose risperidone daily. She was discharged with the diagnosis of delirium due
to another medical condition (TBI), acute, hyperactive. Since discharge, symptoms have not
recurred even after discontinuation of antipsychotic medication.

Conclusions

Clinically, ACS can be divided into hypoactive, hyperactive, and mixed level of
activity. Hyperactive forms may manifest as varying degrees of psychomotor agitation. With
this case report, we’d like to raise awareness of ACS so that it’s diagnosed and treated
correctly and in a timely manner.

Disclosure of Interest

None Declared