Browse categories and answer follow-up questions to refine your symptom profile.
History
Presentation context
Event context
Found down
Witnessed collapse
Last known well time
Baseline mental status
Preceding symptoms
Scene and circumstances
Environment and exposures
Trauma mechanism
Toxic exposure
Fire exposure
Cold exposure
Heat exposure
Access to medications
Timeline
Time course
Sudden onset
Gradual decline
Fluctuating course
Seizure like activity
Postictal period duration
Associated symptoms
Associated symptoms
Fever
Headache
Chest pain
Dyspnea
Vomiting
Focal neurologic symptoms
Incontinence
Tongue biting
Prior episodes
Prior similar episodes
Prior syncope
Prior seizure
Prior hypoglycemia
Prior overdose
Special populations
Population modifiers
Pregnancy possibility
Pediatrics age specific baseline
Older adult baseline cognition
Immunocompromised status
Alarm Features
Immediate life threats
Immediate escalation triggers
Apnea
Hypoventilation with rising CO2
Airway obstruction signs
SpO2 < 90% despite oxygen
SBP < 90 mmHg
HR < 40 or > 130 with instability
Active seizure
GCS <= 8
High risk history
High risk history patterns
Sudden collapse during exertion
Severe headache with collapse
Overdose suspicion
Anticoagulant use with fall
Hypoxia risk setting
Insulin or sulfonylurea exposure
High risk exam findings
High risk exam findings
Absent gag or cough
Unequal pupils
New focal deficit
Meningismus
Signs of trauma
Hyperthermia
Hypothermia
Vital sign danger thresholds
Vital sign danger thresholds
SpO2 < 90%
RR < 8
RR > 30 with fatigue
SBP < 90
MAP < 65
Temp >= 40 C
Temp <= 35 C
Immediate consult triggers
Immediate activation
Airway team
Stroke alert local protocol dependent
Trauma team local protocol dependent
Toxicology support local protocol dependent
Medications
Current and recent
Medication exposure profile
Prescription list
Recent changes
Adherence concerns
PRN sedatives
High risk classes
High risk medication classes
Opioids
Benzodiazepines
Z drugs
Antipsychotics
Tricyclic antidepressants
Beta blockers
Calcium channel blockers
Insulin
Sulfonylureas
Anticoagulants and antiplatelets
Bleeding risk medications
Warfarin
DOACs
Heparin products
Aspirin
P2Y12 inhibitors
Substance co exposures
Substance related exposures
Alcohol
Cannabis
Stimulants
Sedatives
Inhalants
Diet
Intake and hydration
Intake patterns
Poor oral intake
Vomiting with reduced intake
Dehydration risk
Excess free water intake
Caffeine and stimulants
Stimulant intake
Energy drinks
Excess caffeine
Pre workout supplements
Toxin ingestion patterns
Ingestion context
Recent unknown ingestion
Access to toxic alcohols
Access to household chemicals
Review of Systems
Infectious and inflammatory
Infectious symptoms
Fever
Chills
Neck stiffness
Rash
Cardiopulmonary
Cardiopulmonary symptoms
Chest pain
Palpitations
Dyspnea
Cough
Hemoptysis
Neurologic
Neurologic symptoms
Headache
Seizure
Focal weakness
Speech changes
Vision changes
GI and endocrine
GI and endocrine symptoms
Vomiting
Diarrhea
Polyuria
Polydipsia
Weight loss
Toxicologic
Toxicologic features
Confusion before collapse
Somnolence after medication
Agitation then unresponsiveness
Hallucinations
Collateral History and Family History
Collateral source
Collateral reliability
Witness account
EMS report
Family report
Facility staff report
Family history risk
Family history
Sudden cardiac death
Seizure disorders
Inherited arrhythmia syndromes
Social support and supervision
Supervision reliability
Lives alone
Caregiver available
Medication access control
Risk Factors
Cardiovascular and neurologic
Major risk factors
Coronary artery disease history
Heart failure history
Prior stroke or TIA
Atrial fibrillation
Known seizure disorder
Bleeding and trauma
Bleeding and trauma risks
Anticoagulation
Frequent falls
Recent head strike
Known intracranial lesion
Infectious and metabolic
Metabolic and infection risks
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Liver disease (K76.9)
Adrenal insufficiency (E27.40)
Immunosuppression
Toxicologic and environmental
Exposure risks
Opioid use disorder (F11.90)
Alcohol use disorder (F10.20)
Carbon monoxide exposure
Toxic alcohol access
Heat illness risk setting
Hypothermia risk setting
Differential Diagnosis
Life threatening
Life threatening causes
Hypoxia
Airway obstruction
Respiratory failure
Carbon monoxide poisoning (T58)
Hypoglycemia (E16.2)
Insulin exposure
Sulfonylurea exposure
Shock
Sepsis (A41.9)
Hemorrhage
Cardiogenic shock
Intracranial catastrophe
Intracranial hemorrhage (I61.9)
Subarachnoid hemorrhage (I60.9)
Large vessel ischemic stroke (I63.9)
Status epilepticus (G40.901)
Ongoing seizure without convulsions
Postictal airway compromise
Overdose
Opioid toxicity (T40.2)
Sedative hypnotic toxicity (T42.4)
TCA toxicity (T43.0)
Severe electrolyte derangement
Hyperkalemia (E87.5)
Hyponatremia (E87.1)
DKA or HHS (E10.10)
Dehydration
Acidosis
Common
Common causes
Alcohol intoxication (F10.129)
Drug intoxication
Syncope with prolonged recovery
Postictal state
Concussion (S06.0X)
Uremia (N19)
Hypercapnia
Less common
Less common causes
CNS infection
Meningitis (G03.9)
Encephalitis (G04.90)
Wernicke encephalopathy (E51.2)
Myxedema coma
Thyroid storm
Malignant hyperthermia
Neuroleptic malignant syndrome (G21.0)
Mimics and pitfalls
Mimics and pitfalls
Locked in syndrome
Eye movement preserved
Quadriplegia
Catatonia
Normal vitals possible
Waxy flexibility
Psychogenic unresponsiveness
Normal reflexes
Inconsistent response patterns
Past Medical History
Chronic conditions
Relevant chronic conditions
Epilepsy (G40.909)
Diabetes mellitus (E11.9)
Chronic kidney disease (N18.9)
Cirrhosis (K74.60)
Heart failure (I50.9)
COPD (J44.9)
Obstructive sleep apnea (G47.33)
Prior events
Prior events and care
Prior ICU admission
Prior intubation history
Prior overdose reversal
Prior stroke history
Procedures and devices
Devices and procedures
Pacemaker
ICD
VP shunt
Dialysis access
Physical Exam
Primary survey
Primary survey
Airway
Stridor
Gurgling secretions
Vomitus or blood
Breathing
Work of breathing
Breath sounds asymmetry
End tidal CO2 if available
Circulation
Skin perfusion
Capillary refill
Peripheral pulses
Disability
GCS components
Pupils size and reactivity
Focal deficits
Exposure
Temperature
Rash
Track marks
Trauma signs
Vitals interpretation
Vital patterns
Hypotension pattern
Bradycardia pattern
Tachycardia pattern
Fever pattern
Hypothermia pattern
Neurologic exam
Neurologic key elements
Pupillary response
Gag and cough
Corneal reflex
Motor tone
Posturing
Meningismus
Respiratory exam
Respiratory findings
Wheeze
Crackles
Silent chest
Aspiration evidence
Cardiovascular exam
Cardiovascular findings
Rhythm irregularity
Murmur
JVP elevation
Peripheral edema
Toxidrome screen
Toxidrome patterns
Opioid toxidrome
Miosis
Bradypnea
Anticholinergic toxidrome
Mydriasis
Dry skin
Sympathomimetic toxidrome
Diaphoresis
Hypertension
Cholinergic toxidrome
Bronchorrhea
Salivation
Trauma screen
Trauma indicators
Scalp hematoma
Battle sign
Periorbital ecchymosis
Long bone deformity
Pelvic instability
Lab Studies
Immediate bedside
Immediate POC tests
Capillary glucose
If < 4.0 mmol/L, treat immediately
If recurrent or refractory, consider sulfonylurea
Venous blood gas
pH
pCO2 mmHg
Lactate mmol/L
Pregnancy test
If childbearing potential
Impacts imaging and meds
Core labs
Core labs
CBC
Infection signal
Anemia or hemorrhage signal
Electrolytes
Sodium mmol/L
Potassium mmol/L
Calcium mmol/L
Magnesium mmol/L
Renal function
Creatinine
Uremia contribution
Liver tests
Hepatic encephalopathy consideration
Acetaminophen risk context
Serum ketones
DKA consideration
Starvation ketosis consideration
Toxicology focused
Toxicology labs
Acetaminophen level
Time since ingestion relevance
Treat if above nomogram threshold local protocol dependent
Salicylate level
Mixed respiratory alkalosis and metabolic acidosis pattern
Serial levels if rising concern
Ethanol level
Co ingestion risk
Osmolar gap interpretation
Osmolality
Osmolar gap for toxic alcohols
False elevations pitfalls
Infection and inflammation
Infection evaluation
Blood cultures if sepsis concern
Urinalysis and culture if indicated
CRP or procalcitonin local protocol dependent
Coagulation
Coagulation studies
INR
aPTT
Anticoagulant effect assessment
Cardiac
Cardiac labs
Troponin if ischemia or arrhythmia concern
BNP if heart failure pattern
Imaging
Scoring Systems
Imaging decision tools
Canadian CT Head Rule
Adult minor head injury criteria
Not for GCS < 13
New Orleans Criteria
Alternative minor head injury tool
Higher sensitivity lower specificity pattern
Nexus C spine
If trauma concern
Not reliable with altered mental status
Canadian C spine rule
If alert and stable trauma patient
Not for unresponsive patient
MRI
MRI indications
Suspected posterior circulation stroke with nondiagnostic CT
Suspected encephalitis with persistent altered mental status
Brain tumor or abscess consideration
Spinal cord lesion if exam suggests
CT
CT head
If suspected intracranial hemorrhage
If trauma or anticoagulation with any head injury concern
If new focal deficit
If persistent unexplained decreased consciousness
CT angiography head and neck
Large vessel occlusion concern local protocol dependent
Dissection concern with neck trauma or pain
CT chest
Pulmonary embolism concern with unexplained hypoxia
Aspiration complication concern
Ultrasound
POCUS protocols
Cardiac POCUS
Pericardial effusion
Global systolic function
Lung POCUS
Pneumothorax signs
B lines pulmonary edema pattern
IVC assessment
Volume status context
Limited accuracy in many settings
FAST if trauma concern
Free fluid screening
Does not exclude solid organ injury
Special Tests
Bedside neurologic tests
Bedside neurologic adjuncts
Continuous EEG local protocol dependent
Spot EEG if nonconvulsive seizure concern
Oculocephalic reflex if no C spine concern
Lumbar puncture
Lumbar puncture
If meningitis or encephalitis concern after imaging as appropriate
Contraindications
Signs of elevated ICP
Coagulopathy
Carbon monoxide testing
Carboxyhemoglobin
If smoke exposure or clustered symptoms
Pulse oximetry limitation
Toxic alcohol evaluation
Toxic alcohol workup
Anion gap metabolic acidosis
Osmolar gap support
Calcium oxalate crystals context for ethylene glycol
ECG
Indications and timing
ECG triggers
Unexplained collapse
Suspected overdose with cardiotoxicity risk
Electrolyte derangement concern
High risk patterns
ECG red flags
Wide QRS
QTc prolongation
Brugada pattern
High grade AV block
Ventricular tachyarrhythmia
Toxidrome patterns
Toxidrome related ECG
TCA pattern
QRS widening
Terminal R in aVR
Hyperkalemia pattern
Peaked T waves
QRS widening
QT prolonging agents
Torsades risk
Magnesium role
Assessment
Problem representation
Unresponsive patient syndrome
Primary physiologic threat
Airway failure risk
Ventilation failure risk
Circulatory failure risk
Reversible causes prioritized
Hypoglycemia
Opioid toxicity
Hypoxia
Severity and risk stratification
Severity stratification
GCS <= 8 high risk airway failure
Persistent hemodynamic instability high risk shock
Persistent hypoxia high risk respiratory failure
Leading etiologies
Leading etiology buckets
Toxicologic
Neurologic
Metabolic
Infectious
Traumatic
Cardiogenic
Complications to rule out
Immediate complications
Aspiration pneumonitis
Rhabdomyolysis
Hypothermia
Pressure injury
Plan
First 5 minutes
First 5 minutes workflow
Monitoring and access
Cardiac monitor
Continuous pulse oximetry
Noninvasive BP cycling
IV access x 2
Airway and breathing
Oxygen titration to SpO2 >= 94% unless chronic hypercapnia concern
Bag valve mask ventilation if RR < 8 or inadequate tidal volume
If GCS <= 8 or airway reflex absent, prepare RSI local protocol dependent
Circulation
If SBP < 90 or MAP < 65, isotonic crystalloid bolus 500 mL to 1000 mL
If persistent hypotension after fluids, norepinephrine infusion local protocol dependent
Immediate reversible causes
Capillary glucose
If glucose < 4.0 mmol/L, dextrose IV
If opioid toxidrome, naloxone titration
Temperature management
Active warming if hypothermia
Active cooling if hyperthermia
Reversal and antidotes
Reversal agents and antidotes
Dextrose
D10W 250 mL IV
Recheck glucose in 10 minutes
Thiamine
100 mg IV
If malnutrition or alcohol use risk
Naloxone
0.04 mg IV
Repeat every 2 to 3 minutes to RR and airway protection
If no IV, intranasal 2 mg to 4 mg
Flumazenil avoidance
Contraindicated in chronic benzodiazepine use
Contraindicated in mixed overdose with seizure risk
Seizure management
Seizure treatment pathway
Benzodiazepine first line
Lorazepam 2 mg IV
Repeat once after 5 minutes if ongoing
Second line antiseizure
Levetiracetam 60 mg/kg IV maximum 4500 mg
Valproate IV local protocol dependent
Refractory seizure
Airway control
Continuous infusion local protocol dependent
Shock and sepsis
Shock management
Broad spectrum antibiotics within 1 hour if septic shock concern local protocol dependent
Lactate guided resuscitation
Source control planning
Diagnostic sequencing
Diagnostic sequence
Glucose first
ECG early
VBG and electrolytes early
CT head early if focal findings or trauma risk
Reassessment loop
Reassessment loop
Neuro checks every 15 minutes until stable
Vitals every 5 minutes if unstable
Repeat glucose every 30 to 60 minutes if hypoglycemia risk
Repeat VBG and lactate within 2 hours if shock concern
Disposition
ICU criteria
ICU indications
Mechanical ventilation
Vasopressor requirement
Refractory seizures
Persistent GCS <= 8 after initial stabilization
Inpatient admission criteria
Inpatient admission
Persistent altered mental status of unclear cause
Intracranial pathology on imaging
Sepsis or CNS infection concern
High risk overdose requiring monitoring
Observation pathway
Observation candidates
Reversed hypoglycemia with identified cause and stable monitoring plan
Alcohol intoxication with improving mental status and safe supervision
Single brief seizure with full recovery and established diagnosis
Discharge criteria
Discharge criteria
Return to baseline mental status
Normal vital signs
Cause identified and treated
No high risk co ingestion or delayed toxicity concern
Reliable supervision and follow up
Discharge Instructions
Copy discharge instructions
Discharge instructions
Today you were seen for an episode of unresponsiveness that improved after treatment and observation.
Avoid driving, swimming, heights, and operating machinery until cleared by a clinician.
Do not mix alcohol with sedating medications.
Take medications exactly as prescribed and do not take extra doses.
Return to the emergency department immediately for trouble breathing, chest pain, repeated vomiting, severe headache, new weakness, another episode of unresponsiveness, or any seizure.
Follow up with your primary care clinician within 1 to 3 days, and with neurology or cardiology if recommended.
References
Guidelines and key sources
Core references
American College of Emergency Physicians clinical policies on altered mental status and related presentations local protocol dependent
Neurocritical Care Society status epilepticus guidelines latest version local protocol dependent
American Heart Association ACLS guidelines most recent update local protocol dependent
American Academy of Clinical Toxicology position statements on toxic alcohols local protocol dependent
American Diabetes Association guidance on hypoglycemia recognition and treatment latest version local protocol dependent
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.