Lethargy and Altered Mental Status In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

668 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx72

Presentation profile

›Lethargy and altered mental status pattern

›Decreased arousal

›Confusion

›Somnolence

›Unresponsiveness

›Time course and context

›Sudden onset

›Gradual onset

›Fluctuating course

›Baseline neurodevelopment and behavior

›Baseline interaction

›Baseline speech and motor function

›Prior episodes

›Similar events

›Prior evaluations and diagnoses

Recent events and triggers

›Intercurrent illness timeline

›Fever onset

›URI symptoms onset

›GI symptoms onset

›Trauma possibility

›Witnessed head injury

›Unwitnessed fall

›Exposure history

›Household medications access

›Substances

›Carbon monoxide exposure risk

›Ingestion risk window

›Last seen well time

›Potential access time

Associated symptoms

›Neurologic

›Seizure activity

›Postictal period

›Headache

›Focal weakness

›Ataxia

›Vision change

›Infectious

›Fever

›Neck pain

›Photophobia

›Rash

›Cardiopulmonary

›Dyspnea

›Cyanosis

›Palpitations

›GI and hydration

›Vomiting

›Diarrhea

›Poor intake

›Decreased urine output

›Endocrine and metabolic

›Polyuria

›Polydipsia

›Weight loss

Feeding and elimination

›Intake and hydration

›Last oral intake

›Ability to keep fluids down

›Urine output

›Wet diapers count

›Dysuria

›Stool pattern

›Diarrhea

›Constipation

High yield pediatric specifics

›Age specific risks

›Neonate and young infant serious bacterial infection risk

›Toddler ingestion risk

›Immunization status

›Up to date

›Not up to date

›Sick contacts

›Household illness

›Daycare exposure

02Alarm Features/alarm39

First 5 minutes stabilization triggers

›Immediate resuscitation triggers

›Airway not protected

›Apnea

›Persistent hypoxia

›Shock

›Active seizure

›Danger vital signs

›Hypotension for age

›Severe tachycardia for age

›Bradypnea

›Severe hyperthermia

›Hypothermia

High risk neurologic red flags

›Intracranial process concern

›GCS less than 13

›New focal neurologic deficit

›Persistent vomiting with headache

›CNS infection concern

›Meningismus

›Petechiae or purpura

›Bulging fontanelle

›Non accidental trauma concern

›Inconsistent history

›Bruising patterns concerning for abuse

›Retinal hemorrhage concern signs

Toxicologic red flags

›High risk ingestion signals

›Miosis and respiratory depression

›Hyperthermia and agitation alternating with somnolence

›Wide QRS

›Prolonged QTc

Metabolic and endocrine red flags

›Hypoglycemia risk

›Diabetes medications exposure

›Poor intake with vomiting

›DKA and HHS concern

›Kussmaul respirations

›Dehydration with altered sensorium

›Inborn errors of metabolism concern

›Lethargy after fasting

›Recurrent vomiting episodes

›Failure to thrive

03Medications/meds29

Current and recent medications

›Home medications

›Prescription list

›Recent dose changes

›Over the counter exposures

›Cold and cough products

›Antihistamines

›Acetaminophen products

›Ibuprofen products

›Supplements and herbals

›Melatonin

›Herbal products

High risk medication classes

›Sedatives and opioids

›Benzodiazepines

›Opioids

›Psychotropics

›Tricyclic antidepressants

›Antipsychotics

›Cardiovascular agents

›Beta blockers

›Calcium channel blockers

›Metabolic agents

›Insulin

›Sulfonylureas

Medication allergy considerations

›Antibiotic allergies

›Beta lactams

›Sulfonamides

›Contraindications to likely therapies

›QT prolonging agents history

›G6PD deficiency history

04Diet/diet16

Intake and hydration status

›Recent intake

›Poor oral intake

›Normal intake

›Hydration indicators

›Reduced tears

›Dry mucous membranes

›Decreased urine output

Exposure related diet history

›Caffeine and stimulants

›Energy drinks

›Caffeinated sodas

›Possible toxin ingestion via diet

›Homemade alcohol exposure in household

›Herbal teas or remedies

›Special diets

›Ketogenic diet

›Restrictive intake patterns

05Review of Systems/ros42

General

›Systemic symptoms

›Fever

›Chills

›Weight loss

›Toxic appearance

›Poor perfusion

›Reduced interaction

Neurologic

›Neuro symptoms

›Seizure

›Syncope

›Headache

›Weakness

›Gait instability

HEENT

›Head and neck

›Neck stiffness

›Ear pain

›Sore throat

›Vision and hearing

›Vision change

›Photophobia

Respiratory

›Respiratory symptoms

›Cough

›Shortness of breath

›Wheeze

Cardiovascular

›CV symptoms

›Chest pain

›Palpitations

›Cyanosis

Gastrointestinal

›GI symptoms

›Vomiting

›Diarrhea

›Abdominal pain

Genitourinary

›GU symptoms

›Dysuria

›Hematuria

›Reduced urine output

Skin

›Rash patterns

›Petechiae

›Urticaria

›Signs of trauma

›Bruising

›Burns

06Collateral History and Family History/chafh25

Collateral source and reliability

›Source

›Parent or guardian

›EMS

›School or daycare

›Reliability considerations

›Witnessed timeline

›Multiple caregivers with differing accounts

Family history

›Neurologic

›Epilepsy

›Migraine

›Cardiac

›Sudden unexplained death

›Long QT syndrome

›Metabolic and endocrine

›Type 1 diabetes mellitus (E10.9)

›Inborn errors of metabolism

›Hematologic

›Sickle cell disease (D57.1)

›Bleeding disorders

Social context and supervision

›Home environment

›Access to medications

›Carbon monoxide detector presence

›Safeguarding concerns

›Prior child protective involvement

›Domestic violence exposure

07Risk Factors/rf34

Infection and immunologic risk

›Under immunized status

›Missing Hib

›Missing pneumococcal series

›Immunocompromise

›Chemotherapy

›Chronic steroids

›Indwelling devices

›VP shunt

›Central venous catheter

Toxic exposure risk

›Environmental

›Carbon monoxide exposure

›Pesticides

›Household medication access

›Opioids

›Cannabis edibles

›Clonidine

›Adolescents

›Alcohol exposure

›Polysubstance exposure

Trauma risk

›Accidental mechanisms

›Fall from height

›MVC

›Non accidental trauma

›Age under 2 years

›Prior sentinel injuries

Metabolic risk

›Diabetes risk

›Known diabetes

›New onset symptoms of hyperglycemia

›Dehydration risk

›Prolonged vomiting

›Prolonged diarrhea

Cardiac risk

›Arrhythmia risk

›Family history sudden death

›Exertional syncope history

08Differential Diagnosis/ddx61

Life threatening

›CNS infection

›Bacterial meningitis (G00.9)

›Encephalitis (G04.90)

›Intracranial hemorrhage

›Traumatic ICH (S06.5)

›Non traumatic ICH (I61.9)

›Sepsis and shock

›Sepsis (A41.9)

›Septic shock (R65.21)

›Hypoglycemia (E16.2)

›Insulin exposure

›Reduced intake in infant

›DKA (E10.10)

›Kussmaul respirations

›Dehydration

›Toxic ingestion

›Opioid toxicity (T40.2)

›Sedative hypnotic toxicity (T42.4)

›Tricyclic antidepressant toxicity (T43.0)

›Carbon monoxide poisoning (T58)

›Multiple household members symptomatic

›Headache with lethargy

›Status epilepticus

›Ongoing convulsions

›Nonconvulsive status concern

Common

›Dehydration from gastroenteritis

›Reduced intake

›Tachycardia

›Febrile illness with sleep deprivation

›Viral syndrome

›Poor sleep

›Postictal state after seizure

›Witnessed seizure

›Gradual return to baseline

›Medication side effect

›Antihistamines

›Cough and cold products

›Concussion (S06.0)

›Recent head injury

›Headache

Less common

›Brain tumor (D49.6)

›Progressive headaches

›Morning vomiting

›Stroke

›Pediatric ischemic stroke (I63.9)

›Cerebral venous sinus thrombosis (I67.6)

›Metabolic disorders

›Hyperammonemia (E72.20)

›Hypothyroidism (E03.9)

›Intussusception (K56.1)

›Episodic lethargy with abdominal pain

›Intermittent crying spells

Key mimics and pitfalls

›Apparent lethargy from hypoxia

›Silent hypoxemia

›Bronchiolitis

›Apparent lethargy from hypothermia

›Environmental exposure

›Sepsis in neonate

›Overreliance on normal initial exam

›Early meningitis with minimal signs

›Early intracranial bleed with subtle findings

09Past Medical History/pmh24

Medical conditions and prior events

›Neurologic history

›Epilepsy (G40.909)

›Prior CNS infection

›Endocrine and metabolic

›Diabetes mellitus (E10.9)

›Adrenal insufficiency (E27.40)

›Cardiac history

›Congenital heart disease (Q24.9)

›Known arrhythmia

›Renal and electrolyte history

›Chronic kidney disease (N18.9)

›Prior hyponatremia (E87.1)

Procedures and devices

›CNS devices

›VP shunt

›Recent shunt revision

›Other devices

›G tube

›Central line

Baseline function

›Functional baseline

›Usual feeding

›Usual mobility

›Care needs

›Home nursing

›Seizure rescue plan

10Physical Exam/exam61

Initial global assessment

›ABC and stability

›Airway protection

›Work of breathing

›Perfusion

›Vital signs interpretation

›Fever pattern

›Hypotension for age

›Oxygen saturation trend

›Mental status

›Pediatric GCS components

›AVPU

General and hydration

›Appearance

›Toxic appearance

›Consolability

›Hydration

›Capillary refill

›Mucous membranes

›Skin turgor

Head and neck

›Head exam

›Scalp hematoma

›Bulging fontanelle

›Meningeal signs

›Neck stiffness

›Photophobia

›ENT

›Otitis media signs

›Pharyngitis signs

Neurologic exam

›Pupils

›Size symmetry

›Reactivity

›Motor

›Tone

›Strength asymmetry

›Coordination and gait

›Ataxia

›Truncal instability

›Reflexes

›Hyperreflexia

›Hyporeflexia

Cardiopulmonary

›Respiratory

›Breath sounds asymmetry

›Wheeze

›Stridor

›Cardiovascular

›Murmur

›Gallop

›Peripheral pulses

Abdomen

›Abdominal exam

›Tenderness

›Distension

›Mass

›Bowel sounds

›High pitched

›Absent

Skin and trauma survey

›Rash

›Petechiae

›Purpura

›Injury patterns

›Bruising in nonmobile child

›Patterned bruising

›Burns

11Lab Studies/labs62

Point of care immediate tests

›POC glucose

›If less than 3.0 mmol/L treat immediately

›Repeat glucose 10 to 15 minutes after treatment

›Venous blood gas

›pH and CO2 assessment

›Lactate if shock concern

›Urinalysis and ketones

›Ketones positive supports DKA context

›UTI clues

Core labs by syndrome

›CBC with differential

›Leukocytosis support for infection

›Neutropenia immunocompromise risk

›Electrolytes

›Sodium

›Potassium

›Bicarbonate

›Renal function

›Urea

›Creatinine

›Liver panel

›AST

›ALT

›Inflammatory markers

›CRP

›Procalcitonin local protocol dependent

Sepsis and CNS infection workup

›Blood culture

›Before antibiotics when feasible

›Do not delay antibiotics in shock

›Serum lactate

›Elevated supports hypoperfusion

›Trend for response

›CSF studies when LP performed

›Cell count and differential

›Glucose

›Protein

Toxicology and targeted labs

›Acetaminophen level

›Time since ingestion dependent interpretation

›Repeat level per nomogram guidance

›Salicylate level

›Serial levels if concern

›Mixed respiratory alkalosis and metabolic acidosis pattern

›Ethanol level

›Correlate with clinical state

›Co ingestants common

›Urine drug screen

›Limited sensitivity and specificity

›Does not reliably detect all synthetics

›Carboxyhemoglobin

›Measure in suspected carbon monoxide exposure

›Pulse oximetry can be falsely normal

Metabolic and endocrine evaluation

›Beta hydroxybutyrate

›Supports DKA if elevated

›Starvation ketosis context

›Serum osmolality

›Toxic alcohol evaluation context

›Hypernatremia context

›Ammonia

›Consider if unexplained encephalopathy

›Handle specimen quickly to reduce false elevation

›TSH and free T4

›Consider if prolonged altered sensorium

›Hypothermia bradycardia context

12Imaging/img34

Scoring Systems

›Pediatric head trauma decision support

›PECARN head trauma criteria

›Applicable for GCS 14 to 15 and blunt head trauma

›Altered mental status sepsis screening

›Pediatric qSOFA is not validated for disposition decisions

›Use institutional sepsis pathway local protocol dependent

MRI

›Brain MRI indications

›Concern for encephalitis with nondiagnostic CT

›Posterior fossa process suspicion

›MRI contraindications and logistics

›Implanted ferromagnetic device

›Need for sedation risk

›Interpretation pearls

›Diffusion restriction in acute ischemia

›Temporal lobe involvement in HSV encephalitis pattern

›Non contrast CT head indications

›GCS less than 13

›Focal neurologic deficit

›Signs of increased intracranial pressure

›CT radiation considerations

›Pediatric dose reduction protocols

›Alternative imaging if stable and low risk

›CT contrast considerations

›Contrast allergy history

›Renal dysfunction risk

Ultrasound

›Abdominal ultrasound indications

›Intussusception concern

›Appendicitis concern with atypical presentation

›POCUS role

›IVC assessment in shock context

›Lung ultrasound for pneumonia and effusion context

›Limitations and pitfalls

›Operator dependence

›False negatives early in disease course

13Special Tests/spec21

Lumbar puncture decision logic

›LP prerequisites

›Hemodynamic stability

›No signs of impending herniation

›LP deferral triggers

›Focal neurologic deficit with concern for mass effect

›Severely depressed consciousness with airway risk

›CSF interpretation pearls

›WBC count age dependent normal ranges

›Traumatic tap confounding

EEG considerations

›Nonconvulsive status epilepticus concern

›Persistent altered mental status without explanation

›Subtle automatisms

›Timing considerations

›Early EEG if persistent AMS after convulsive seizure

›Continuous EEG in ICU local protocol dependent

Toxicology consult triggers

›Poison control involvement

›Unknown ingestion

›Sustained release exposure

›Decontamination constraints

›Activated charcoal only if protected airway

›Caustic ingestion excludes charcoal

14ECG/ecg13

Indications in pediatric AMS

›ECG indications

›Suspected ingestion

›Syncope preceding lethargy

›Electrolyte derangement concern

›High risk ECG findings

›QRS greater than 100 ms

›QTc prolongation

›Patterns suggesting specific toxidromes

›Terminal R in aVR with TCA toxicity concern

›Bradycardia with AV block in beta blocker exposure concern

›Serial ECG logic

›Repeat every 2 hours if evolving tox picture

›Continuous monitoring if QRS or QTc abnormal

15Assessment/ax27

Problem representation

›Pediatric lethargy and altered mental status

›Duration category

›Presence of fever

›Presence of trauma or ingestion possibility

›Severity stratification

›GCS category

›Respiratory support need

›Hemodynamic stability

Leading diagnoses with supporting data

›CNS infection concern

›Fever with meningismus

›Rash with petechiae or purpura

›Toxic ingestion concern

›Access to medications

›Abnormal pupils

›ECG abnormalities

›Metabolic derangement concern

›Hypoglycemia on POC

›Acidosis on blood gas

›Intracranial pathology concern

›Focal deficits

›Signs of increased intracranial pressure

Diagnostic uncertainty framing

›Complications to rule out

›Airway compromise

›Seizure recurrence

›Alternative diagnoses

›Intussusception with episodic lethargy

›Sepsis without fever in young infant

16Plan/plan40

Immediate stabilization

›Airway and breathing

›Supplemental oxygen for hypoxia

›Bag mask ventilation if apnea

›Circulation

›IV or IO access if unstable

›Isotonic fluid bolus 20 mL/kg for shock

›Reassess after each bolus

›Glucose management

›If glucose less than 3.0 mmol/L dextrose

›D10W 5 mL/kg IV

›D25W 2 mL/kg IV

›Seizure management

›If active seizure benzodiazepine

›Lorazepam IV 0.1 mg/kg

›Midazolam IN 0.2 mg/kg

Time critical empiric therapy

›Suspected sepsis or meningitis

›Antibiotics within 60 minutes for sepsis pathway local protocol dependent

›Ceftriaxone IV 50 mg/kg

›Add vancomycin IV 15 mg/kg if resistant pneumococcus risk

›Suspected encephalitis

›Acyclovir IV 10 mg/kg every 8 hours

›Renal dosing adjustment if kidney dysfunction

›Suspected opioid toxicity

›Naloxone IV 0.1 mg/kg

›Repeat every 2 to 3 minutes to effect

Diagnostic sequencing

›First line tests

›POC glucose

›VBG

›Electrolytes

›CBC

›Second line tests by suspicion

›Blood cultures if infection concern

›Toxicology labs if exposure concern

›Carboxyhemoglobin if CO concern

Monitoring and reassessment loop

›Monitoring

›Cardiorespiratory monitoring

›Frequent vitals every 15 minutes if unstable

›Reassessment timing

›Neuro checks every 30 to 60 minutes initially

›Repeat glucose after dextrose within 10 to 15 minutes

17Disposition/dispo25

ICU criteria

›ICU level care triggers

›Need for airway support

›Persistent GCS less than 13

›Refractory seizures

›Shock needing vasoactives

Inpatient admission criteria

›Admission indications

›Suspected CNS infection

›Ingestion requiring monitoring

›Persistent abnormal labs

›Observation pathway

›Improving mental status

›Normalizing vitals

›Clear diagnosis with low risk course

Transfer criteria

›Higher level pediatric center triggers

›Need for pediatric ICU

›Neurosurgical concern

›Continuous EEG need

Discharge criteria

›Discharge requirements

›Return to baseline mental status

›Normal vitals for age

›Tolerating oral intake

›Reliable caregiver supervision

›Follow up timing

›Primary care within 24 to 48 hours

›Specialty follow up if indicated

18Discharge Instructions/di25

Copy discharge instructions

›Summary

›Today you were seen for sleepiness and behavior change

›Testing did not show an emergency cause at this time

›Hydration and intake

›Encourage frequent small sips of fluids

›Monitor urine output

›Medications

›Use only medicines prescribed or recommended today

›Avoid cough and cold medicines unless specifically instructed

›Activity

›Quiet rest for 24 hours

›No risky activities if head injury concern

›Follow up

›Follow up with your primary care clinician in 1 to 2 days

›Return sooner if symptoms worsen

›Return to ED now for

›Trouble breathing

›Blue lips or face

›Seizure

›Not waking up normally

›New weakness

›Stiff neck

›Purple or spreading rash

›Persistent vomiting

›Signs of dehydration

19References/r18

Guidelines and key sources

›Pediatric Advanced Life Support guidelines, American Heart Association, 2020

›Pediatric resuscitation algorithms

›Pediatric shock management

›Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children, 2020

›Time sensitive antibiotics and fluids

›Vasoactive escalation framework

›PECARN Pediatric Head Trauma Prediction Rules, original validation studies, 2009

›Imaging reduction strategy

›Risk stratification for clinically important TBI

›American Academy of Pediatrics guidance on evaluation of febrile infants, 2021

›Age based SBI evaluation

›Disposition frameworks

›Infectious Diseases Society of America encephalitis guidelines, 2018

›Empiric acyclovir indications

›Diagnostic testing recommendations

›Poison control and toxicology management resources, local protocol dependent

›Regional toxidrome management pathways

›Decontamination criteria

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Lethargy and Altered Mental Status In The ChildAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

668 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx72

Presentation profile

›Lethargy and altered mental status pattern

›Decreased arousal

›Confusion

›Somnolence

›Unresponsiveness

›Time course and context

›Sudden onset

›Gradual onset

›Fluctuating course

›Baseline neurodevelopment and behavior

›Baseline interaction

›Baseline speech and motor function

›Prior episodes

›Similar events

›Prior evaluations and diagnoses

Recent events and triggers

›Intercurrent illness timeline

›Fever onset

›URI symptoms onset

›GI symptoms onset

›Trauma possibility

›Witnessed head injury

›Unwitnessed fall

›Exposure history

›Household medications access

›Substances

›Carbon monoxide exposure risk

›Ingestion risk window

›Last seen well time

›Potential access time

Associated symptoms

›Neurologic

›Seizure activity

›Postictal period

›Headache

›Focal weakness

›Ataxia

›Vision change

›Infectious

›Fever

›Neck pain

›Photophobia

›Rash

›Cardiopulmonary

›Dyspnea

›Cyanosis

›Palpitations

›GI and hydration

›Vomiting

›Diarrhea

›Poor intake

›Decreased urine output

›Endocrine and metabolic

›Polyuria

›Polydipsia

›Weight loss

Feeding and elimination

›Intake and hydration

›Last oral intake

›Ability to keep fluids down

›Urine output

›Wet diapers count

›Dysuria

›Stool pattern

›Diarrhea

›Constipation

High yield pediatric specifics

›Age specific risks

›Neonate and young infant serious bacterial infection risk

›Toddler ingestion risk

›Immunization status

›Up to date

›Not up to date

›Sick contacts

›Household illness

›Daycare exposure

02Alarm Features/alarm39

First 5 minutes stabilization triggers

›Immediate resuscitation triggers

›Airway not protected

›Apnea

›Persistent hypoxia

›Shock

›Active seizure

›Danger vital signs

›Hypotension for age

›Severe tachycardia for age

›Bradypnea

›Severe hyperthermia

›Hypothermia

High risk neurologic red flags

›Intracranial process concern

›GCS less than 13

›New focal neurologic deficit

›Persistent vomiting with headache

›CNS infection concern

›Meningismus

›Petechiae or purpura

›Bulging fontanelle

›Non accidental trauma concern

›Inconsistent history

›Bruising patterns concerning for abuse

›Retinal hemorrhage concern signs

Toxicologic red flags

›High risk ingestion signals

›Miosis and respiratory depression

›Hyperthermia and agitation alternating with somnolence

›Wide QRS

›Prolonged QTc

Metabolic and endocrine red flags

›Hypoglycemia risk

›Diabetes medications exposure

›Poor intake with vomiting

›DKA and HHS concern

›Kussmaul respirations

›Dehydration with altered sensorium

›Inborn errors of metabolism concern

›Lethargy after fasting

›Recurrent vomiting episodes

›Failure to thrive

03Medications/meds29

Current and recent medications

›Home medications

›Prescription list

›Recent dose changes

›Over the counter exposures

›Cold and cough products

›Antihistamines

›Acetaminophen products

›Ibuprofen products

›Supplements and herbals

›Melatonin

›Herbal products

High risk medication classes

›Sedatives and opioids

›Benzodiazepines

›Opioids

›Psychotropics

›Tricyclic antidepressants

›Antipsychotics

›Cardiovascular agents

›Beta blockers

›Calcium channel blockers

›Metabolic agents

›Insulin

›Sulfonylureas

Medication allergy considerations

›Antibiotic allergies

›Beta lactams

›Sulfonamides

›Contraindications to likely therapies

›QT prolonging agents history

›G6PD deficiency history

04Diet/diet16

Intake and hydration status

›Recent intake

›Poor oral intake

›Normal intake

›Hydration indicators

›Reduced tears

›Dry mucous membranes

›Decreased urine output

Exposure related diet history

›Caffeine and stimulants

›Energy drinks

›Caffeinated sodas

›Possible toxin ingestion via diet

›Homemade alcohol exposure in household

›Herbal teas or remedies

›Special diets

›Ketogenic diet

›Restrictive intake patterns

05Review of Systems/ros42

General

›Systemic symptoms

›Fever

›Chills

›Weight loss

›Toxic appearance

›Poor perfusion

›Reduced interaction

Neurologic

›Neuro symptoms

›Seizure

›Syncope

›Headache

›Weakness

›Gait instability

HEENT

›Head and neck

›Neck stiffness

›Ear pain

›Sore throat

›Vision and hearing

›Vision change

›Photophobia

Respiratory

›Respiratory symptoms

›Cough

›Shortness of breath

›Wheeze

Cardiovascular

›CV symptoms

›Chest pain

›Palpitations

›Cyanosis

Gastrointestinal

›GI symptoms

›Vomiting

›Diarrhea

›Abdominal pain

Genitourinary

›GU symptoms

›Dysuria

›Hematuria

›Reduced urine output

Skin

›Rash patterns

›Petechiae

›Urticaria

›Signs of trauma

›Bruising

›Burns

06Collateral History and Family History/chafh25

Collateral source and reliability

›Source

›Parent or guardian

›EMS

›School or daycare

›Reliability considerations

›Witnessed timeline

›Multiple caregivers with differing accounts

Family history

›Neurologic

›Epilepsy

›Migraine

›Cardiac

›Sudden unexplained death

›Long QT syndrome

›Metabolic and endocrine

›Type 1 diabetes mellitus (E10.9)

›Inborn errors of metabolism

›Hematologic

›Sickle cell disease (D57.1)

›Bleeding disorders

Social context and supervision

›Home environment

›Access to medications

›Carbon monoxide detector presence

›Safeguarding concerns

›Prior child protective involvement

›Domestic violence exposure

07Risk Factors/rf34

Infection and immunologic risk

›Under immunized status

›Missing Hib

›Missing pneumococcal series

›Immunocompromise

›Chemotherapy

›Chronic steroids

›Indwelling devices

›VP shunt

›Central venous catheter

Toxic exposure risk

›Environmental

›Carbon monoxide exposure

›Pesticides

›Household medication access

›Opioids

›Cannabis edibles

›Clonidine

›Adolescents

›Alcohol exposure

›Polysubstance exposure

Trauma risk

›Accidental mechanisms

›Fall from height

›MVC

›Non accidental trauma

›Age under 2 years

›Prior sentinel injuries

Metabolic risk

›Diabetes risk

›Known diabetes

›New onset symptoms of hyperglycemia

›Dehydration risk

›Prolonged vomiting

›Prolonged diarrhea

Cardiac risk

›Arrhythmia risk

›Family history sudden death

›Exertional syncope history

08Differential Diagnosis/ddx61

Life threatening

›CNS infection

›Bacterial meningitis (G00.9)

›Encephalitis (G04.90)

›Intracranial hemorrhage

›Traumatic ICH (S06.5)

›Non traumatic ICH (I61.9)

›Sepsis and shock

›Sepsis (A41.9)

›Septic shock (R65.21)

›Hypoglycemia (E16.2)

›Insulin exposure

›Reduced intake in infant

›DKA (E10.10)

›Kussmaul respirations

›Dehydration

›Toxic ingestion

›Opioid toxicity (T40.2)

›Sedative hypnotic toxicity (T42.4)

›Tricyclic antidepressant toxicity (T43.0)

›Carbon monoxide poisoning (T58)

›Multiple household members symptomatic

›Headache with lethargy

›Status epilepticus

›Ongoing convulsions

›Nonconvulsive status concern

Common

›Dehydration from gastroenteritis

›Reduced intake

›Tachycardia

›Febrile illness with sleep deprivation

›Viral syndrome

›Poor sleep

›Postictal state after seizure

›Witnessed seizure

›Gradual return to baseline

›Medication side effect

›Antihistamines

›Cough and cold products

›Concussion (S06.0)

›Recent head injury

›Headache

Less common

›Brain tumor (D49.6)

›Progressive headaches

›Morning vomiting

›Stroke

›Pediatric ischemic stroke (I63.9)

›Cerebral venous sinus thrombosis (I67.6)

›Metabolic disorders

›Hyperammonemia (E72.20)

›Hypothyroidism (E03.9)

›Intussusception (K56.1)

›Episodic lethargy with abdominal pain

›Intermittent crying spells

Key mimics and pitfalls

›Apparent lethargy from hypoxia

›Silent hypoxemia

›Bronchiolitis

›Apparent lethargy from hypothermia

›Environmental exposure

›Sepsis in neonate

›Overreliance on normal initial exam

›Early meningitis with minimal signs

›Early intracranial bleed with subtle findings

09Past Medical History/pmh24

Medical conditions and prior events

›Neurologic history

›Epilepsy (G40.909)

›Prior CNS infection

›Endocrine and metabolic

›Diabetes mellitus (E10.9)

›Adrenal insufficiency (E27.40)

›Cardiac history

›Congenital heart disease (Q24.9)

›Known arrhythmia

›Renal and electrolyte history

›Chronic kidney disease (N18.9)

›Prior hyponatremia (E87.1)

Procedures and devices

›CNS devices

›VP shunt

›Recent shunt revision

›Other devices

›G tube

›Central line

Baseline function

›Functional baseline

›Usual feeding

›Usual mobility

›Care needs

›Home nursing

›Seizure rescue plan

10Physical Exam/exam61

Initial global assessment

›ABC and stability

›Airway protection

›Work of breathing

›Perfusion

›Vital signs interpretation

›Fever pattern

›Hypotension for age

›Oxygen saturation trend

›Mental status

›Pediatric GCS components

›AVPU

General and hydration

›Appearance

›Toxic appearance

›Consolability

›Hydration

›Capillary refill

›Mucous membranes

›Skin turgor

Head and neck

›Head exam

›Scalp hematoma

›Bulging fontanelle

›Meningeal signs

›Neck stiffness

›Photophobia

›ENT

›Otitis media signs

›Pharyngitis signs

Neurologic exam

›Pupils

›Size symmetry

›Reactivity

›Motor

›Tone

›Strength asymmetry

›Coordination and gait

›Ataxia

›Truncal instability

›Reflexes

›Hyperreflexia

›Hyporeflexia

Cardiopulmonary

›Respiratory

›Breath sounds asymmetry

›Wheeze

›Stridor

›Cardiovascular

›Murmur

›Gallop

›Peripheral pulses

Abdomen

›Abdominal exam

›Tenderness

›Distension

›Mass

›Bowel sounds

›High pitched

›Absent

Skin and trauma survey

›Rash

›Petechiae

›Purpura

›Injury patterns

›Bruising in nonmobile child

›Patterned bruising

›Burns

11Lab Studies/labs62

Point of care immediate tests

›POC glucose

›If less than 3.0 mmol/L treat immediately

›Repeat glucose 10 to 15 minutes after treatment

›Venous blood gas

›pH and CO2 assessment

›Lactate if shock concern

›Urinalysis and ketones

›Ketones positive supports DKA context

›UTI clues

Core labs by syndrome

›CBC with differential

›Leukocytosis support for infection

›Neutropenia immunocompromise risk

›Electrolytes

›Sodium

›Potassium

›Bicarbonate

›Renal function

›Urea

›Creatinine

›Liver panel

›AST

›ALT

›Inflammatory markers

›CRP

›Procalcitonin local protocol dependent

Sepsis and CNS infection workup

›Blood culture

›Before antibiotics when feasible

›Do not delay antibiotics in shock

›Serum lactate

›Elevated supports hypoperfusion

›Trend for response

›CSF studies when LP performed

›Cell count and differential

›Glucose

›Protein

Toxicology and targeted labs

›Acetaminophen level

›Time since ingestion dependent interpretation

›Repeat level per nomogram guidance

›Salicylate level

›Serial levels if concern

›Mixed respiratory alkalosis and metabolic acidosis pattern

›Ethanol level

›Correlate with clinical state

›Co ingestants common

›Urine drug screen

›Limited sensitivity and specificity

›Does not reliably detect all synthetics

›Carboxyhemoglobin

›Measure in suspected carbon monoxide exposure

›Pulse oximetry can be falsely normal

Metabolic and endocrine evaluation

›Beta hydroxybutyrate

›Supports DKA if elevated

›Starvation ketosis context

›Serum osmolality

›Toxic alcohol evaluation context

›Hypernatremia context

›Ammonia

›Consider if unexplained encephalopathy

›Handle specimen quickly to reduce false elevation

›TSH and free T4

›Consider if prolonged altered sensorium

›Hypothermia bradycardia context

12Imaging/img34

Scoring Systems

›Pediatric head trauma decision support

›PECARN head trauma criteria

›Applicable for GCS 14 to 15 and blunt head trauma

›Altered mental status sepsis screening

›Pediatric qSOFA is not validated for disposition decisions

›Use institutional sepsis pathway local protocol dependent

MRI

›Brain MRI indications

›Concern for encephalitis with nondiagnostic CT

›Posterior fossa process suspicion

›MRI contraindications and logistics

›Implanted ferromagnetic device

›Need for sedation risk

›Interpretation pearls

›Diffusion restriction in acute ischemia

›Temporal lobe involvement in HSV encephalitis pattern

›Non contrast CT head indications

›GCS less than 13

›Focal neurologic deficit

›Signs of increased intracranial pressure

›CT radiation considerations

›Pediatric dose reduction protocols

›Alternative imaging if stable and low risk

›CT contrast considerations

›Contrast allergy history

›Renal dysfunction risk

Ultrasound

›Abdominal ultrasound indications

›Intussusception concern

›Appendicitis concern with atypical presentation

›POCUS role

›IVC assessment in shock context

›Lung ultrasound for pneumonia and effusion context

›Limitations and pitfalls

›Operator dependence

›False negatives early in disease course

13Special Tests/spec21

Lumbar puncture decision logic

›LP prerequisites

›Hemodynamic stability

›No signs of impending herniation

›LP deferral triggers

›Focal neurologic deficit with concern for mass effect

›Severely depressed consciousness with airway risk

›CSF interpretation pearls

›WBC count age dependent normal ranges

›Traumatic tap confounding

EEG considerations

›Nonconvulsive status epilepticus concern

›Persistent altered mental status without explanation

›Subtle automatisms

›Timing considerations

›Early EEG if persistent AMS after convulsive seizure

›Continuous EEG in ICU local protocol dependent

Toxicology consult triggers

›Poison control involvement

›Unknown ingestion

›Sustained release exposure

›Decontamination constraints

›Activated charcoal only if protected airway

›Caustic ingestion excludes charcoal

14ECG/ecg13

Indications in pediatric AMS

›ECG indications

›Suspected ingestion

›Syncope preceding lethargy

›Electrolyte derangement concern

›High risk ECG findings

›QRS greater than 100 ms

›QTc prolongation

›Patterns suggesting specific toxidromes

›Terminal R in aVR with TCA toxicity concern

›Bradycardia with AV block in beta blocker exposure concern

›Serial ECG logic

›Repeat every 2 hours if evolving tox picture

›Continuous monitoring if QRS or QTc abnormal

15Assessment/ax27

Problem representation

›Pediatric lethargy and altered mental status

›Duration category

›Presence of fever

›Presence of trauma or ingestion possibility

›Severity stratification

›GCS category

›Respiratory support need

›Hemodynamic stability

Leading diagnoses with supporting data

›CNS infection concern

›Fever with meningismus

›Rash with petechiae or purpura

›Toxic ingestion concern

›Access to medications

›Abnormal pupils

›ECG abnormalities

›Metabolic derangement concern

›Hypoglycemia on POC

›Acidosis on blood gas

›Intracranial pathology concern

›Focal deficits

›Signs of increased intracranial pressure

Diagnostic uncertainty framing

›Complications to rule out

›Airway compromise

›Seizure recurrence

›Alternative diagnoses

›Intussusception with episodic lethargy

›Sepsis without fever in young infant

16Plan/plan40

Immediate stabilization

›Airway and breathing

›Supplemental oxygen for hypoxia

›Bag mask ventilation if apnea

›Circulation

›IV or IO access if unstable

›Isotonic fluid bolus 20 mL/kg for shock

›Reassess after each bolus

›Glucose management

›If glucose less than 3.0 mmol/L dextrose

›D10W 5 mL/kg IV

›D25W 2 mL/kg IV

›Seizure management

›If active seizure benzodiazepine

›Lorazepam IV 0.1 mg/kg

›Midazolam IN 0.2 mg/kg

Time critical empiric therapy

›Suspected sepsis or meningitis

›Antibiotics within 60 minutes for sepsis pathway local protocol dependent

›Ceftriaxone IV 50 mg/kg

›Add vancomycin IV 15 mg/kg if resistant pneumococcus risk

›Suspected encephalitis

›Acyclovir IV 10 mg/kg every 8 hours

›Renal dosing adjustment if kidney dysfunction

›Suspected opioid toxicity

›Naloxone IV 0.1 mg/kg

›Repeat every 2 to 3 minutes to effect

Diagnostic sequencing

›First line tests

›POC glucose

›VBG

›Electrolytes

›CBC

›Second line tests by suspicion

›Blood cultures if infection concern

›Toxicology labs if exposure concern

›Carboxyhemoglobin if CO concern

Monitoring and reassessment loop

›Monitoring

›Cardiorespiratory monitoring

›Frequent vitals every 15 minutes if unstable

›Reassessment timing

›Neuro checks every 30 to 60 minutes initially

›Repeat glucose after dextrose within 10 to 15 minutes

17Disposition/dispo25

ICU criteria

›ICU level care triggers

›Need for airway support

›Persistent GCS less than 13

›Refractory seizures

›Shock needing vasoactives

Inpatient admission criteria

›Admission indications

›Suspected CNS infection

›Ingestion requiring monitoring

›Persistent abnormal labs

›Observation pathway

›Improving mental status

›Normalizing vitals

›Clear diagnosis with low risk course

Transfer criteria

›Higher level pediatric center triggers

›Need for pediatric ICU

›Neurosurgical concern

›Continuous EEG need

Discharge criteria

›Discharge requirements

›Return to baseline mental status

›Normal vitals for age

›Tolerating oral intake

›Reliable caregiver supervision

›Follow up timing

›Primary care within 24 to 48 hours

›Specialty follow up if indicated

18Discharge Instructions/di25

Copy discharge instructions

›Summary

›Today you were seen for sleepiness and behavior change

›Testing did not show an emergency cause at this time

›Hydration and intake

›Encourage frequent small sips of fluids

›Monitor urine output

›Medications

›Use only medicines prescribed or recommended today

›Avoid cough and cold medicines unless specifically instructed

›Activity

›Quiet rest for 24 hours

›No risky activities if head injury concern

›Follow up

›Follow up with your primary care clinician in 1 to 2 days

›Return sooner if symptoms worsen

›Return to ED now for

›Trouble breathing

›Blue lips or face

›Seizure

›Not waking up normally

›New weakness

›Stiff neck

›Purple or spreading rash

›Persistent vomiting

›Signs of dehydration

19References/r18

Guidelines and key sources

›Pediatric Advanced Life Support guidelines, American Heart Association, 2020

›Pediatric resuscitation algorithms

›Pediatric shock management

›Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children, 2020

›Time sensitive antibiotics and fluids

›Vasoactive escalation framework

›PECARN Pediatric Head Trauma Prediction Rules, original validation studies, 2009

›Imaging reduction strategy

›Risk stratification for clinically important TBI

›American Academy of Pediatrics guidance on evaluation of febrile infants, 2021

›Age based SBI evaluation

›Disposition frameworks

›Infectious Diseases Society of America encephalitis guidelines, 2018

›Empiric acyclovir indications

›Diagnostic testing recommendations

›Poison control and toxicology management resources, local protocol dependent

›Regional toxidrome management pathways

›Decontamination criteria

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.