What are the differential diagnoses and immediate emergency management for an unconscious 14‑year‑old female?

Unconscious Collapse in a 14-Year-Old Female

Immediate Management: Follow the Pediatric BLS Algorithm

Immediately verify scene safety, check responsiveness while simultaneously assessing breathing and pulse within 10 seconds, and if no pulse or heart rate <60/min with poor perfusion is detected, start CPR with 30:2 compressions-to-breaths (or 15:2 if two rescuers) while activating emergency services. 1, 2

Initial Assessment Sequence

• Scene safety first: Ensure you are not at risk before approaching the patient 1
• Check responsiveness: Shout and tap the patient's shoulders 1, 2
• Shout for help: Designate a second rescuer to activate emergency services and retrieve AED/emergency equipment 1
• Simultaneous pulse and breathing check: Within 10 seconds, assess for normal breathing (not just gasping) and palpate a central pulse 1, 2

Decision Tree Based on Initial Assessment

If pulse present with normal breathing:

• Monitor continuously until emergency responders arrive 1
• Consider hypoglycemia as a critical reversible cause (see below)

If pulse present but no normal breathing or only gasping:

• Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths/minute) 1
• Reassess pulse every 2 minutes 1
• If heart rate drops below 60/min with signs of poor perfusion, immediately start CPR 1, 3

If no pulse or only gasping with no breathing:

• Start CPR immediately with high-quality chest compressions 1, 2
• Single rescuer: 30 compressions to 2 breaths 1, 4
• Two or more rescuers: 15 compressions to 2 breaths 1, 2, 4
• Compression depth: at least one-third anterior-posterior chest diameter (~5 cm) 2, 4
• Compression rate: 100-120/minute with complete chest recoil 2, 4
• Apply AED as soon as available and follow prompts 1, 2

Critical Early Interventions

Check blood glucose immediately (within the first 11 minutes of presentation) as hypoglycemia occurs in 18% of pediatric resuscitations and significantly increases mortality. 5 In adolescents presenting with impaired consciousness and recent symptom onset (<12 hours), hypoglycemia due to metabolic disorders should be strongly suspected. 6

Defibrillation protocol:

• If shockable rhythm (VF/pulseless VT): deliver 1 shock, then immediately resume CPR for 2 minutes before rechecking rhythm 1, 2
• If non-shockable rhythm (asystole/PEA): resume CPR immediately without attempting defibrillation 1, 4

Medication administration (once vascular access obtained):

• Epinephrine 0.01 mg/kg IV/IO (0.1 mL/kg of 0.1 mg/mL concentration), maximum 1 mg, repeat every 3-5 minutes 2, 4
• For refractory VF/pulseless VT: amiodarone 5 mg/kg IV/IO bolus or lidocaine 1 mg/kg 2
• Never use atropine in pediatric cardiac arrest 4

Differential Diagnosis Framework

Life-Threatening Causes Requiring Immediate Recognition

Cardiac causes:

• Arrhythmias (long QT syndrome, hypertrophic cardiomyopathy, commotio cordis)
• Structural heart disease
• Myocarditis

Metabolic emergencies:

• Hypoglycemia (most common reversible cause in this age group, especially with recent illness or fasting) 5, 6
• Diabetic ketoacidosis
• Inborn errors of metabolism (rare but critical—suspect with severe hypoglycemia, neuroglycopenic symptoms, and rapid onset) 6

Neurological causes:

• Seizure with post-ictal state
• Intracranial hemorrhage (trauma, vascular malformation)
• Increased intracranial pressure
• Status epilepticus

Toxicological causes:

• Drug overdose (opioids, sedatives, alcohol)
• Carbon monoxide poisoning

Respiratory causes:

• Severe asthma with respiratory failure
• Pulmonary embolism
• Tension pneumothorax

Infectious causes:

• Septic shock (hypoglycemia present in many cases) 5
• Meningitis/encephalitis

Other causes:

• Vasovagal syncope (benign but must exclude dangerous causes first)
• Hemorrhagic shock (trauma, ruptured ectopic pregnancy)
• Anaphylaxis

Key Clinical Pitfalls to Avoid

• Never delay CPR to obtain history, labs, or imaging when cardiac arrest criteria are met 4
• Never attempt defibrillation for asystole—this wastes critical time 4
• Never skip glucose testing—hypoglycemia is present in nearly 1 in 5 pediatric resuscitations and has nonspecific signs 5, 6
• Never use atropine in pediatric cardiac arrest as it delays appropriate epinephrine administration 4
• Change compressors every 2 minutes to prevent fatigue and maintain compression quality 2

Post-Resuscitation Considerations

Once return of spontaneous circulation is achieved, transport to a specialized cardiac arrest center should be considered for advanced post-cardiac arrest care including targeted temperature management and comprehensive evaluation. 7