Category: Case-log

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 until today. She’d had a fever earlier and I brought her in because she’s had a fit before, with a fever, some time ago.”

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!,” comes from a senior colleague who has just arrived on the other side of the bed, clearly unimpressed at what looks, from a fresh set of eyes, like the child being moved mid-event.

This is one of the peculiar hazards of a shared resuscitation space: two clinicians, arriving at slightly different points in an evolving picture, can reasonably reach two different readings of the same few seconds. You’re somewhat startled by the directness of it, but the moment passes quickly enough — everyone’s attention is, rightly, on the child.

Still assessing “anew,” the senior colleague opts for a more cautious path and gives intramuscular midazolam, which the child duly receives from the nurse: 0.15 mg/kg.

“Who are you?”

“That’s Dr [——],” interjects another nurse, by way of introduction. “He’s one of our GPs.”

The colleague continues, arranging the child’s transfer to hospital by ambulance. The child has settled. The child didn’t enjoy the injection (a moot point). In hindsight the injection likely wasn’t needed (no harm was done). But the child had it all the same. And you’re left standing at the bedside, turning over how differently two reasonable clinicians, working from the same set of facts a few seconds apart, can land.

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:

Tintinalli’s Emergency Medicine, handbook

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 to one part or side; paraesthesia, metallic tastes, and visual or auditory hallucinations
• complex: impaired consciousness; simple partial seizure progressing with impaired consciousness; aura preceding altered consciousness (auditory, olfactory, or visual hallucinations); may generalize

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, or 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? In a shared acute space, seniority, timing of arrival, and who last laid eyes on the patient can each pull rank in a different direction — worth having a clear, agreed protocol for who leads a resuscitation once more than one clinician is present, before the next code, rather than working it out in real time.

Reference

Rosen and Barkin’s 5-Minute Emergency Medicine Consult, 5th Edn. Wolters Kluwer.