Signs of raised intracranial pressure local protocol dependent
Viral respiratory testing local protocol dependent
RSV
Influenza
Capillary blood smear if anemia concern
Hemolysis clues
Artifact limitations
Bedside response trials
Therapeutic diagnostic responses
Nasal suction response
Improved feeding after suctioning
Persistent work of breathing despite suctioning
Glucose correction response
Improved alertness after dextrose
Recurrent hypoglycemia suggests endocrine or metabolic cause
ECG
Indications and high risk patterns
ECG use in lethargy and poor feeding
Indications
Persistent tachycardia unexplained
Cyanosis or shock without clear source
High risk findings
Supraventricular tachycardia
Complete heart block
Conduction patterns
Long QT interval
Pre excitation pattern
Serial ECG and monitoring logic
Rhythm surveillance
Continuous monitoring
If unstable then continuous monitoring
If intermittent symptoms then capture during episode
Repeat ECG triggers
After cardioversion or adenosine
After electrolyte correction
Assessment
Problem representation and severity
Clinical synthesis
Severity tier
Ill appearing with altered mental status
Well appearing but decreased intake
Physiologic risk
Signs of shock
Respiratory failure risk
Age based risk stratification
Less than 28 days higher invasive bacterial infection risk
29 to 90 days intermediate risk local protocol dependent
Working diagnoses and competing threats
Working diagnostic framework
Serious bacterial infection risk
Sepsis
Meningitis
Metabolic endocrine risk
Hypoglycemia
Adrenal crisis
Cardiorespiratory risk
Bronchiolitis with feeding failure
Congenital heart disease decompensation
GI surgical risk
Malrotation with volvulus if bilious emesis
Intussusception if episodic lethargy
Plan
Immediate stabilization and monitoring
Stabilization sequence
Airway and breathing
If apnea or inadequate ventilation then bag valve mask ventilation
If SpO2 less than 92 percent then oxygen
Circulation
If poor perfusion then isotonic fluid bolus 10 mL per kg
Reassessment after each bolus
Glucose correction
Dextrose D10W 2 mL per kg IV or IO for symptomatic hypoglycemia
Recheck glucose in 15 minutes
Temperature management
Active warming if hypothermic
Antipyretic dosing weight based local protocol dependent
Empiric antimicrobials and antivirals
Time critical infection treatment
If suspected sepsis then antibiotics within 60 minutes local protocol dependent
Neonate or young infant empiric regimen local protocol dependent
Ampicillin IV weight based
Gentamicin IV weight based
Alternative regimen local protocol dependent
Ampicillin IV weight based
Cefotaxime IV weight based
HSV coverage triggers
Vesicular rash
Seizure
Transaminitis
Acyclovir IV weight based if HSV concern
Renal dosing adjustment prompt
Ensure hydration
Fluids and vasopressors
Shock management
Fluid strategy
10 mL per kg bolus increments in neonate local protocol dependent
20 mL per kg bolus increments in older infant local protocol dependent
Vasopressor escalation local protocol dependent
If persistent shock after fluids then epinephrine infusion
If warm shock pattern then norepinephrine option
Diagnostic sequencing and reassessment loop
Reassessment loop
Timing
Recheck vitals every 15 minutes if unstable
Recheck perfusion after each intervention
Targets
Improving mental status
Improving perfusion markers
Failure to improve triggers escalation
Persistent lethargy
Rising lactate or worsening acidosis
Consultation
Specialty involvement
Pediatrics
Any ill appearing infant
Any infant less than 28 days with poor feeding or lethargy
PICU
Need for respiratory support
Shock requiring vasoactive support
Pediatric surgery
Bilious vomiting
Intussusception concern
Child protection team
Bruising in non mobile infant
Concerning caregiver history
Disposition
ICU criteria
Higher level of care criteria
Respiratory support requirement
High flow nasal cannula
Non invasive ventilation
Shock physiology
Need for vasopressors
Recurrent fluid boluses with persistent poor perfusion
Neurologic compromise
Seizure
Persistent altered mental status
Inpatient admission criteria
Admission indications
Age based
Less than 28 days with lethargy or poor feeding
Less than 90 days with serious bacterial infection concern
Feeding failure
Inadequate oral intake with dehydration
Need for NG or IV fluids
Infection management
IV antibiotics required
Pending cultures with high risk features
Observation and discharge criteria
Lower acuity pathways
Observation pathway criteria local protocol dependent
Well appearing after ED interventions
Normal glucose and stable vitals
Discharge criteria
Normal mental status for age
Adequate oral intake observed in ED
Follow up timing
Primary care within 24 hours
Earlier follow up if cultures pending local protocol dependent
Discharge Instructions
Copy discharge instructions
Summary
Seen today for decreased feeding and sleepiness
Current exam and tests do not show an emergency cause right now
Feeding and hydration
Smaller frequent feeds
Wet diapers should increase over the next day
Medications
Use medications only as directed for age and weight
Do not use leftover antibiotics
Follow up
Follow up with your primary care clinician within 24 hours
Return sooner if you cannot get follow up
Return to emergency now for
Trouble breathing
Blue lips or face
Hard to wake
Seizure
Fever in a young infant local protocol dependent
Low temperature with sleepiness
No wet diapers for 8 hours
Repeated vomiting
Green vomiting
Blood in stool
New rash with purple spots
References
Guidelines and key sources
Evidence based references
American Academy of Pediatrics clinical practice guideline for well appearing febrile infants 8 to 60 days 2021
Surviving Sepsis Campaign international guidelines for management of septic shock and sepsis associated organ dysfunction in children 2020
National Institute for Health and Care Excellence sepsis recognition diagnosis and early management NG51 updated regularly local protocol dependent
World Health Organization IMCI danger signs and young infant illness guidance updated regularly
Infectious Diseases Society of America guidance on management of bacterial meningitis updated regularly
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.