Neurological Emergencies and Altered Mental Status
The pediatric neurological exam is anchored in serial reassessments rather than a single snapshot. Use AVPU or the age-appropriate Glasgow Coma Scale and document pupils, symmetry, and posturing. In infants, a bulging or tense fontanel, sunset eyes, macrocephaly, and vomiting suggest raised intracranial pressure; in older children look for headache, vomiting, and a declining level of consciousness. The Cushing triad - hypertension with bradycardia and irregular respirations - is a late, pre-herniation sign and should never be the trigger for action.
Seizures
Febrile seizures occur between 6 months and 5 years with fever and no CNS infection; the key exam trap is distinguishing a simple febrile seizure (generalized, under 15 minutes, one in 24 hours, normal exam) from a complex one. Status epilepticus is treated with a benzodiazepine first: lorazepam 0.1 mg/kg IV (max 4 mg) or midazolam 0.2 mg/kg intranasal or intramuscular (max 10 mg), repeated once, then a second-line anticonvulsant. Always check glucose in any seizing or altered child.
Infection, injury, and shunts
Bacterial meningitis requires antibiotics before lumbar puncture in an unstable or septic-appearing child - do not delay treatment for imaging. Head injury triage uses mechanism, loss of consciousness, vomiting, and exam findings; signs of a basilar skull fracture (hemotympanum, raccoon eyes, CSF rhinorrhea) mandate imaging. Children with ventricular shunts who present with vomiting, headache, or lethargy need shunt evaluation urgently.
Rule of thumb: a child who is not improving mentally after a seizure, trauma, or glucose correction needs imaging and a broader workup, not observation.