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Medical Emergencies

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Objectives

• Describe the potential causes and outline the management of seizures in children

• Discuss the implication of fever as a presenting sign in children

• Discuss common causes of altered level of consciousness (ALOC)

• List signs and symptoms of hypoglycemia and hyperglycemia, and outline management

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3-year-old child

• You are called to the home of a child who has had a fever for one day

• Prior to your arrival she experiences a single generalized seizure followed by confusion

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3-year-old child

Circulation to SkinNormal color

Work of BreathingNormal

AppearanceDrowsy, but interacts

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Initial Assessment

• Airway - Open, no stridor • Breathing - RR 25 breaths/min, clear breath

sounds • Circulation - HR 115 beats/min; skin warm to

the touch; normal capillary refill; BP 105/65 mm Hg

• Child begins to have another seizureWhat are your treatment and transport priorities?

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Treatment Priorities

• Place oxygen 15L/minby face mask

• Suction airway as needed• Consider placing a NP

airway• Be ready to support

breathing with BVM ventilation

• Transport

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Treatment PrioritiesBLS treatment priorities plus…• Assess serum glucose, treat if

< 60 mg%• Administer a benzodiazepine

• Diazepam - PR or IV• Midazolam - IM or IV

• Place patient on a cardiac monitor and pulse oximeter

• Transport when seizure stops

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• Child receives 0.5 mg/kg (6 mg) diazepam PR

• Child stops seizing and respiratory rate drops to 4 breaths/min

Should the child be intubated?Should you transport immediately?

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• Respiratory depression is the most common complication of seizures and can occur after benzodiazepine administration.

• Place a NP airway and begin BVM ventilation.

• Transport and continue BVM en route to the emergency department.

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Seizures in Children

• Epilepsy: seizure disorder defined by > 2 afebrile seizures

• Status epilepticus: 2 seizures without regaining consciousness, or prolonged seizure

• Febrile Seizure: seizure associated with fever in an infant or child 6 months to 5 years of age and without other cause

What are some of the possible causes of seizures in children?

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Etiologies of Seizures

• Fever • Hypoglycemia

• Head trauma • Metabolic disorder

• Hypoxia • Bleeding into brain

• Infection • Low level anti-seizure medicine

• Ingestion

What is the significance of fever in this patient?

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Fever

• Fever may indicate a serious infection in the blood or central nervous system.

• Ominous signs suggesting a serious cause: bulging fontanelle, stiff neck, prolonged CRT, purplish rash

• Newborns and young infants may have nonspecific symptoms of serious infection such as fussiness, poor feeding, or decreased activity.

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Fever

• Temperature < 105º F is not harmful and does not cause brain damage.

• Treatment: Body substance precautions, passive cooling

• Transport priorities: If initial assessment is normal, do focused history and physical exam, and detailed physical exam on scene; if initial assessment is abnormal, treat en route to the hospital

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4-year-old child

• You are dispatched to the home of a child “not acting right”.

• She was recently diagnosed with diabetes and is on insulin.

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4-year-old child

Circulation to SkinNormal color

Work of BreathingNormal

AppearanceDisoriented

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Initial Assessment

• Airway - Open, no stridor • Breathing - RR 30 breaths/min, clear

breath sounds, SaO2 96% • Circulation - HR 140 beats/min; skin

moist and warm; CRT 2 seconds; BP 95/65 mm Hg

• Disability - AVPU=V, normal pupillary response to light

• Exposure - No sign of trauma

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What are the potential causes of this child’s ALOC?

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ALOC Etiologies

• Alcohol • Trauma, temperature • Epilepsy, endocrine, • Infection

electrolytes • Psychogenic, poison • Insulin • Shock, space

occupying• Opiates, overdose lesion, subarachnoid• Uremia hemorrhage

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ALOC Assessment

• Look for an identifying bracelet or other information that could give a clue to the cause of ALOC

What are your initialmanagement and transportpriorities?

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Treatment Priorities

• Position the head and open the airway• Provide oxygen 15L by facemask or as

tolerated• Consider placement of a NP airway• Prepare to perform BVM ventilation as

needed• Consider immobilization of the spine• Transport after airway management is

initiated

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Treatment Priorities

BLS priorities plus...• Check blood glucose level

• If < 60 mg%, give D50W 1 ml/kg bolus via IV

• If IV not obtainable, give glucagon 1 mg IM

• Consider naloxone

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• Blood glucose value 30 mg%

• Child becomes alert and interactive after D50W IV

• Perform focused history and physical exam, and detailed physical exam on scene

• Patient transported to the emergency department for further care

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Hypoglycemia

• Serum glucose < 60 mg% in an infant or child and < 40 mg% in a newborn

• Common etiologies:• Starvation or sepsis• Too much insulin• Intoxication (alcohol or other drugs)• Metabolic defects

• Signs and symptoms may be subtle• Lethargy, pallor, sweating, tachycardia

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Hyperglycemia

• Hyperglycemia can lead to dehydration and ketoacidosis

• Symptoms include increased thirst and urination

• Signs of shock may be present

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Conclusion

• Airway and ventilatory support are the most important aspects of seizure and ALOC management.

• Fever itself will rarely harm a child but may be a sign of a serious infection.

• Check blood glucose level in all children with ALOC.