AdultPediatric
Quick links · seizure types & pathways
AMS in a child is a medical emergency. Check glucose immediately. AEIOU-TIPS framework drives the workup. Always consider non-accidental trauma (NAT) and toxic ingestion.
🚩 Red-flag clues (must not miss)
- •Posturing, anisocoria, Cushing triad (HTN + bradycardia + irregular respirations) = ↑ICP / herniation
- •Bulging fontanelle in infant = ↑ICP / meningitis / NAT
- •Retinal hemorrhages = abusive head trauma (NAT) until proven otherwise
- •Bradycardia + AMS in young child = late shock / herniation
- •Glucose < 60 mg/dL — treat before any other workup
History
- Onset (sudden vs gradual), trauma, fever, ingestions in home
- Recent fasting, diabetes, inborn error of metabolism
- Seizure activity, post-ictal state
- Caregiver inconsistencies — consider NAT
Exam
- GCS (pediatric scale < 2 y), pupils, fundoscopy, fontanelle
- Skin: bruising patterns, burns, petechiae, needle marks
- Tone, reflexes, posturing, focal deficits
- Breath odor (fruity = DKA, bitter almond, garlic)
Labs
- Bedside glucose (FIRST)
- VBG, lactate, ammonia
- BMP, Mg, Phos, Ca
- CBC, blood culture
- UA + urine tox + serum acetaminophen, salicylate, EtOH
- LP after CT if meningitis suspected and no contraindication
Imaging
- Non-contrast head CT for trauma, focal deficit, signs of ↑ICP
- MRI brain (with & without contrast) if stroke, encephalitis, or demyelinating disease
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| AEIOU-TIPS — Alcohol / Abuse | Bruises, burns, retinal heme | Skeletal survey, social work, NAT protocol |
| Epilepsy / post-ictal | Witnessed seizure, tongue bite | AED level, EEG, MRI brain (with & without contrast) if first-time |
| Insulin / hypoglycemia | Glucose < 60 | D10 2–5 mL/kg IV (D25 0.5–1 g/kg older) |
| Opioids / overdose | Pinpoint pupils, hypoventilation | Naloxone 0.1 mg/kg IV/IM/IN |
| Uremia / metabolic | Hyperammonemia, acidosis | Metabolic w/u, dialysis if severe |
| Trauma (incl. NAT) | Retinal heme, mismatched story | CT head (without contrast), skeletal survey, NAT consult |
| Infection (meningitis/encephalitis) | Fever + AMS + nuchal | Empiric ceftriaxone + vanc + acyclovir; LP |
| Psychogenic | Diagnosis of exclusion | Rule out organic first |
| Stroke (rare in peds) | Sickle cell, focal deficit | Emergent MRI brain (with & without contrast) + MRA head/neck (with contrast), hematology |
Medications & dosing
| Drug | Dose | Notes |
|---|---|---|
| Dextrose D10W | 2–5 mL/kg IV bolus | First-line for hypoglycemia in infants/young children |
| Naloxone | 0.1 mg/kg IV/IM/IN (max 2 mg) | Repeat q2–3 min PRN; expect short half-life |
| Ceftriaxone | 100 mg/kg IV (max 4 g) for meningitis | Avoid in neonates < 28 d with hyperbili / Ca-containing IVF — use cefotaxime |
| Vancomycin | 15 mg/kg IV q6h | Add for empiric meningitis pending cx |
| Acyclovir | 20 mg/kg IV q8h (neonate); 10–15 mg/kg q8h (older) | Add if HSV encephalitis suspected |
Management / next steps
- ABCs — protect airway if GCS ≤ 8 or no gag
- Bedside glucose; D10 if hypoglycemic
- Empiric antibiotics + acyclovir if febrile/meningitic
- Naloxone if opioid possible
- CT head (without contrast) before LP if focal deficit, papilledema, or signs of ↑ICP
- Admit ICU; consult PICU, neurology, toxicology as indicated
Source: https://fprmed.com/fprmedcom/Pages/Pedi/Neuro_pedi/AMS.html
← Back to Pediatric DDx