Transcript 6.Seizure and Uncounciousness

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
• How will you manage seizure in your office ?
Treatment of febrile convulsions
•Drugs
Febrile since oneRoute
day
Dose
Midazolam
Buccal
• Developmentally normal
0.25-0.5 mg/kg/do
Nasal
• Febrile convulsions in a sibling
IV
0.2mg/kg/do
(4puffs/10kg)
0.05-0.1 mg/kg /do
Lorazepam
IV
0.05-0.1mg/kg
Diazepam
PR
0.5mg/kg/dose
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?
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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
Case 2
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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 -
Case 2 contd
O/E
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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?
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?
How Deeply is the Child Unconscious?
For AVPU
and GCS
Refer
SOS-HOPE
APP
• 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
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
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
When to Intubate?
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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
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
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
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
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
• Dextrose : 36 mg%
• Dextrose
• D5
• D10
(0.25-1 g/kg)
10cc/kg
5 cc/kg
• Remember to start an infusion
Management Continued…
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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