Thursday, December 21, 2023
1300 hrs
A child is brought in by her mother and she seems unwell, febrile, pale and, at reception, as mum is checking her child in the child collapses–starts shaking, stops breathing.
Code Blue. You’re in your room, in between patients, and the alarm goes off. You wonder if in fact it could be a false alarm; but, of course, you get your stethoscope and with some trepidation calmly walk towards the resuscitation room. In fact, you are walking behind a mother carrying her child–the patient–and a handful of nurses ushering her by. And by the time you round the curtain by the bedside—they had a head-start and were making tracks—you find the child with face mask on being nursed in the recovery position. There is a scramble, mother kneels by the bedside holding the child’s hand and one nurse stands back recording the staff actions and another is taking observations.
You bring a common garden approach to the situation, as you make for the head of the bed and at once notice the child’s mask misting up and the child’s chest making rhythmic breathing movements. The child looks a little pale but apart from that nothing stands out about the child. So, you listen to the (front and sides) of the chest and there is good air entry on both sides, without added sounds. You turn to the mother just the other side of the bed.
“What happened?”
“She just stopped breathing outside in the waiting room.”
“When did she become unwell?”
“She was well. At Daycare today they called me at about 12 to say that she had a fever to 39 and to come and pick her up. I took her home and gave her some Panadol and some lunch. She ate it up. Then this afternoon her temperature went to 40 and I brought her here, because she’s had a fit before.”
“When was that?”
“One year ago.”
“She had a high fever and then had a fit.”
Here is a child who presents to a GP clinic with (presumptive) febrile fit. The child is breathing and settling. You quickly but briefly have the child gently propped up and listen to her chest— Then, “Hey. Stop that!,” is the cry that comes from a rotund but strong person diametrically opposed on the other side of the bed. You’re somewhat startled and somewhat bewildered by this person rousing on you in what amounts to a clear suggestion that yours was an act of indiscretion: moving the (post-ictal) child. As the child is clearly settling into a rhythmic breathing, this “attending” now confronting you (a FACEM fellow) isn’t.
Still in code mode, the attending, who you don’t see because they arrived later on the scene quickly assesses the situation “anew,” and determines to give the child intramuscular midazolam, which the child duly receives from the dutiful nurse: 0.15 mg per kg.
“Who are you?, the attending demands?”
“That’s Dr ……”, interjects another dutiful nurse, by way of your introduction to the attending. “He’s one of our new GPs.”
The attending huffs and puffs and goes on the business arranging the child’s transfer to hospital by ambulance. The child has settled. The child didn’t enjoy the injection (a moot point). The child didn’t need the injection (no harm was done). But the child had the injection all the same. And you get left standing at the bedside.
The infant who presents with fitting will likely have a febrile fit and, in the appropriate setting, management should be expectant with attention to ABCs. Little more will need to be done for this child except for observation for 3-4 hours and then, with the likelihood of a fever-induced fit from a self-limiting viral illness, with normal mentation and neurological exam, and the child can safely be discharged home with careful instruction to the parent.
In the immediate instant; however, the differential diagnosis will vary according to the exact age group of the child:
| in the neonate: | in the infant or toddler: | older children and adolescents |
| apnoea due to other causes | breath-holding spells | migraine headache |
| jitters/tremors | night terrors | syncope |
| GOR | pseudoseizures | |
| hysteria |
While these thoughts are running through your head, act:
- Perform bedside blood glucose (for all young infants and those in status)
- EUC, BUN, Creat., Glc, CMP, CBC, and Tox. screen in other children depending on examination findings.
- +/- AED (anti-epileptic drug) level
- Septic (SBI) screen for febrile seizure
As you check the child once over (primary survey), in the neonate look for:
- subtle abnormal repetitive motor activity
- respiratory alterations
- apnoea
- seizure activity
- generalized signs, such as that of a metabolic problem or infection that may present with focal seizures: skin exam
In the older child look for:
generalized seizures:
- tonic-clonic, tonic or clonic
- myoclonic
- atonic (“drop attack”)
- absence
partial/focal seizures:
- simple: consciousness maintained.
- simple partial:
- motor, sensory, and/or cognitive symptoms
- motor activity focal: 1 part or side
- paraesthesia, metallic tastes, and visual or auditory hallucinations
- complex:
- impaired consciousness
- complex partial:
- simple partial seizure progresses with impaired consciousness
- aura precedes altered consciousness; auditory, olfactory, or visual hallucinations
- may generalize
- simple partial seizure progresses with impaired consciousness
status epilepticus:
- generalized is most common
- sustained partial seizures
- absence seizures
- persistent confusion; post-ictal period
Infants who are sick get a head CT and/or lumbar puncture.
Stabilize:
- O2 via NPA or BVM
- IV dextrose:
- 5 mL/kg D10 for the neonate
- 2 mL/kg D25 for the child
- treat status: use preferentially either
- buccal midazolam: 0.2 mg/kg
- nasal lorazepam: 0.1 mg/kg
- PR diazepam: 0.2-0.5 mg/kg
- +/- (fos)phenytoin: 15-20 mg/kg slow IV over 30 min.
- +/- phenobarbital: 15-20 mg/kg IV over 20 min.
Whose super-clinic is it anyway? Well, that depends on your individual “pre-test probability.”
The next day you are “summoned” to the attendant’s, and you resign yourself to (politely) ignoring the message.
Reference
Rosen and Barkin’s 5-Minute Emergency Medicine Consult. 5th Edn. Wolters Kluwer.
