2
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
3
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
4
3-year-old child
Circulation to SkinNormal color
Work of BreathingNormal
AppearanceDrowsy, but interacts
5
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?
6
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
7
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
8
• 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?
9
• 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.
10
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?
11
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?
12
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.
13
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
14
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.
16
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
18
ALOC Etiologies
• Alcohol • Trauma, temperature • Epilepsy, endocrine, • Infection
electrolytes • Psychogenic, poison • Insulin • Shock, space
occupying• Opiates, overdose lesion, subarachnoid• Uremia hemorrhage
19
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?
20
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
21
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
22
• 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
23
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
24
Hyperglycemia
• Hyperglycemia can lead to dehydration and ketoacidosis
• Symptoms include increased thirst and urination
• Signs of shock may be present