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Seizures & Unconscious Child

Seizures & Unconscious Child. Case 1. 1 year old female bought convulsing to emergency GTC seizure Started 5 minutes ago Altered sensorium following seizures Temp-39.5 degrees C, Pulse-155/min RR-40/min, BP-100/60 mmhg, GCS: 12/15 , Oxygen Sat-99%, cap refill<2secs

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Seizures & Unconscious Child

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  1. Seizures & Unconscious Child

  2. Case 1 • 1 year old female bought convulsing to emergency • GTC seizure • Started 5 minutes ago • Altered sensorium following seizures • Temp-39.5 degrees C, Pulse-155/min RR-40/min, BP-100/60 mmhg, GCS: 12/15 , Oxygen Sat-99%, cap refill<2secs • How will you manage seizure in your office ?

  3. Treatment of febrile convulsions • Febrile since one day • Developmentally normal • Febrile convulsions in a sibling

  4. What questions should one ask to elicit history? • Does s/he have a fever? • Does s/he have a seizure disorder? • If yes, is s/he on anti-seizure medications? • If yes, is s/he taking them, or any recent changes? • Any trauma? • Any medicines s/he had access to? • How was s/he before the seizure started? • Is s/he developmentally normal? • Family h/o epilepsy/febrile seizures

  5. Case 2 • 4 month, M brought in by mother with • H/o fever for 2 days • H/o altered sensorium for 2days • H/o irritability and refusal to feed • T-38.8 degrees C, P-170/min, RR-25/min, BP-110/80mmhg, Oxygen sat-89% • Triage category -

  6. Case 2 contd O/E • Anterior fontanelle bulging • Pupils are reactive • CVS: normal • RS - AE equal, but shallow breaths • PA - distended • CNS - irritability present, intermittent decerebration present • Key Information that you would elicit?

  7. Case 2 contd • Is the child unconscious and if so, how deeply? • Is the intracranial pressure raised? • Are there possible underlying causes which should be treated immediately • What is the emergency management of the unconscious patient?

  8. For AVPU and GCS Refer SOS-HOPE APP How Deeply is the Child Unconscious? • Various scales like Glasgow coma scale or AVPU scale can be used to assess the depth of coma • Periodic assessments are required • If unsure, it is preferable to estimate on the side of recording to a lower score

  9. Is the Intracranial Pressure Raised? • Always assume that the ICP is raised in all cases of unconscious child as appropriate management is required in the acute situation to prevent death and handicap • The main goals of care include • Optimizing cerebral blood flow (CBF)/cerebral perfusion pressure (CPP) • Minimizing factors that can aggravate neuronal injury or trigger intracranial pressure (ICP) elevation like pain, uncontrolled seizures, high fever, fluid overload

  10. What is the Emergency Management of the Unconscious Patient? • Airway: positioning, suction, artificial / advanced airway , start oxygen • Breathing pattern shallow: prepare for early intubation • Circulation: establish early IV/IO access • Treat immediately correctable causes: Dx, Na • Osmotic therapy: mannitol 0.25 to 1 gm/kg(infusion) • Control of seizures: midaz, lorazepam • Control fever: paracetamol

  11. When to Intubate? • Loss of airway protective reflexes • Apnea /gasping • SpO2 < 92% • Pupils: Anisocoria > 1 mm/dilated/poorly reacting pupils • Glasgow Coma Scale (GCS) score < 9 • Fall in GCS score of > 3, irrespective of initial GCS

  12. Case 3 • 7 yrs old male was found convulsing in sleep by his parents. He is a known epileptic since last 1 yr and was running fever since 2 days • Parents have given him midazolam spray 2 times, but convulsions persisted • On examination, HR: 150/min, RR: 34/min, BP:86/42 mmhg, SpO2: 86% • Triage category ? • Any child presenting with convulsions, classify as status epilepticus

  13. Treatment of refractory seizure • Airway: positioning, suction, artificial / advanced airway , start oxygen • Breathing pattern shallow: prepare for early intubation • Circulation: establish early iv access • IV lorazepam is the drug of choice for termination. If no IV access use midazolam in buccal/rectal/intranasal routes

  14. Case 4 • PS, 2 yrs, M was brought to emergency with alleged h/o repeated vomiting for 1 day • H/o refusal to feed since morning • There was progressive worsening of sensorium • O/E: Temp 38.8 degreec C,HR: 130/min, BP: 110/ 80 mmHg,RR: 28/min, shallow respirations,GCS: 9/15, pt stuporous.Pulse Oximetry 90% ,Cap Refill 4 secs Pupils: equal and reacting well • TRIAGE

  15. Getting Started… • Airway: positioning, suction, artificial / advanced airway • Breathing pattern shallow: prepare for early intubation • Circulation: establish early iv access • Draw samples for easily correctable causes of coma: Dx, Na, Samples for toxic screen, critical sample for IEM can be collected if possible • Disability: use AVPU scale

  16. Dextrose : 36 mg% • Dextrose (0.25-1 g/kg) • D5 10cc/kg • D10 5 cc/kg • Remember to start an infusion

  17. Management Continued… • Neurologic assessment • Assess for evidence of raised intracranial pressure • Assess for focal neurologic disease/ seizures • If concern for infection, give first dose of III gen cephalosporin • Give specific antidotes if toxic exposures are known

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