{"id":979,"date":"2022-04-02T07:20:02","date_gmt":"2022-04-02T07:20:02","guid":{"rendered":"http:\/\/scribblingsofamedic.com\/?p=979"},"modified":"2022-04-02T07:20:02","modified_gmt":"2022-04-02T07:20:02","slug":"medical-case-10-the-fitting-child","status":"publish","type":"post","link":"https:\/\/scribblingsofamedic.com\/index.php\/2022\/04\/02\/medical-case-10-the-fitting-child\/","title":{"rendered":"MEDICAL CASE 10 &#8211; THE FITTING CHILD"},"content":{"rendered":"<p>This is one of the commonest emergencies in paediatrics. A fitting child. Post-ictal. Or during the ictal phase. They come in all stages of a fit.<\/p>\n<p>Whilst attending to the patient, one of the most useful things would be to ensure that the parent remains calm. This is a very hard task, but it will not help to have a screaming hysterical parent rolling along the ground whilst you try to control the patient\u2019s seizure.<\/p>\n<p><strong>So what happened?<\/strong><\/p>\n<p>A 3 year old boy was brought into the ward in a state of convulsion. According to the quick history taken, the generalised seizure which was unprovoked had started 5 minutes prior involving all 4 limbs. There was drooling and upward rolling of eyes, but no faecal\/urine incontinence associated. The child had no past medical history or any allergies. As this was an emergency, attend to the patient first \u2013 take the thorough history later.<\/p>\n<p><strong>What did you do?<\/strong><\/p>\n<p>As with all emergencies, you must think of the airway, breathing and circulation.<\/p>\n<ul>\n<li>The child should be placed in the left lateral position (recovery) and maintain an open airway.<\/li>\n<li>Place an oxygen mask and attach a saturation probe to the child.<\/li>\n<li>Quickly check the capillary blood glucose to rule out hypoglycaemia as a cause.<\/li>\n<li>As the child has been seizing for more than 5 minutes, rectal diazepam or <em>buccal midazolam\u00a0(0.4-0.5 mg\/kg)<\/em> (not available in Sri Lanka) must be used. <em>Rectal diazepam dose (0.5mg\/kg) \u2013 5mg if &lt;2 year, 5-10 mg if between 2 and 11 \u00a0years, 10-20 mg if more than 12 years.<\/em><\/li>\n<li>At this point I informed my senior because there is a risk of respiratory arrest with benzodiazepine administration.<\/li>\n<li>Wait for 10 minutes for the seizure to resolve, if not a 2nd PR dose of diazepam can be given.<\/li>\n<li>If IV access is available, instead of diazepam give IV lorazepam (0.05-0.1 mg\/kg).<\/li>\n<li>If seizures do not persist then IV phenytoin or IV phenobarbitone has to be administrated (after senior opinion obviously!)<\/li>\n<\/ul>\n<p><strong>The seizure has been settled, what now?<\/strong><\/p>\n<p>On further history taking \u2013 the child had a high grade fever for one day associated with a one day history of a cough and cold. There were no symptoms of infection such as meningitis and the child had no significant past medical history. The child\u2019s father had a febrile seizure as a child.<\/p>\n<p>On examination, the child had post-ictal drowsiness with fever &gt;38.8\u00baC. All vital signs for normal except for a mild tachycardia. Respiratory, abdomen and ENT examination was normal. There were no signs of meningism (rash, neck stiffness, Kernig\u2019s and Brudzinski\u2019s).<\/p>\n<p>Once the seizure settled, I took all the immediate investigations required to rule out other causes of seizures such as:<\/p>\n<ol>\n<li>Hypoglycaemia \u2013 CBS<\/li>\n<li>Infection \u2013 FBC, CRP, B. Culture, UFR, U. Culture and lumbar puncture (ensure no contraindications)<\/li>\n<li>Electrolyte imbalance \u2013 Sodium\/Potassium, Calcium<\/li>\n<\/ol>\n<p>The child was only given simple antipyretics to control the fever (paracetamol SOS). If investigation reports show any abnormalities, then the cause is not a febrile seizure and further specific management is required.<\/p>\n<p>IMPORTANT \u2013 A commonly missed cause of pyrexia in children is tonsillitis and an urine infection so always remember to check the child\u2019s ENT and send a UFR\/U. Culture.<\/p>\n<p>In our case the child only had a simple febrile seizure and the fever settled after 24 hours. The child was also managed with normal saline nasal drops and salbutamol for treatment of the cough and cold. Anti-histamines such as piriton and loratidine are not given as they can be sedative which should not be given to children who have suffered a convulsion.<\/p>\n<p><strong>Advice to parents<\/strong><\/p>\n<p>This is a vital part of the management of patients with febrile convulsions \u2013 especially as there is a chance of recurrence!<\/p>\n<ul>\n<li>Turn the child immediately to their side with their head tilted back slightly to make sure the child doesn\u2019t aspirate any vomit<\/li>\n<li>Move away any objects on the floor that can be of danger<\/li>\n<li>Do not insert anything into the mouth of the child<\/li>\n<li>After the seizure stops, remove any excess clothes.<\/li>\n<li>Do not place the child under running water or directly under a cooling fan. Tepid sponging is also no longer recommended.<\/li>\n<li>If the child has difficulty breathing or the seizure lasts for more than 5 minutes, bring the child to a hospital immediately.<\/li>\n<li>As with the guidelines from the Ministry of Health Sri Lanka on the contraindication and precautionary conditions for vaccinations, the Japanese Encephalitis vaccine must be avoided in those with a past history of convulsions.<\/li>\n<\/ul>\n<p><strong>What are febrile convulsions?<\/strong><\/p>\n<ul>\n<li>Febrile convulsions are fits that occur during a fever (&gt;38\u00baC) without any underlying cause such as hypoglycaemia, electrolyte imbalances and meningitis.<\/li>\n<li>These convulsions commonly occur in children aged between 6 months and 6 years.<\/li>\n<li>Febrile seizures are either <em>simple<\/em> (generalised tonic clonic, lasting less than 15 minutes and with no more than one in 24 hours) or <em>complex<\/em> (can either be focal, lasts more than 15 minutes and may have more than one within 24 hours).<\/li>\n<li>Status epilepticus are seizures lasting more than 30 minutes.<\/li>\n<li>Most seizures are simple in nature.<\/li>\n<li>There is a genetic inheritance pattern, but the mechanism is unknown.<\/li>\n<li>The degree of fever nor the rate of rise determines if a fever will occur.<\/li>\n<li>Children who have had their 1st seizure need a thorough investigation.<\/li>\n<li>If a complex seizure or status epileptics \u2013 the child may need further investigation such as an EEG.<\/li>\n<li>Febrile seizures can recur in 30% of patients, especially in those with a family history and if less than &lt;18 months of age of onset.<\/li>\n<li>There is a 2% risk of the children going onto develop epilepsy.<\/li>\n<\/ul>\n","protected":false},"excerpt":{"rendered":"<p>This is one of the commonest emergencies in paediatrics. A [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":906,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0},"categories":[4],"tags":[138,29,20,60,75,104,23,62,21,120,32,139,22],"_links":{"self":[{"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/posts\/979"}],"collection":[{"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/comments?post=979"}],"version-history":[{"count":1,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/posts\/979\/revisions"}],"predecessor-version":[{"id":980,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/posts\/979\/revisions\/980"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/media\/906"}],"wp:attachment":[{"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/media?parent=979"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/categories?post=979"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/scribblingsofamedic.com\/index.php\/wp-json\/wp\/v2\/tags?post=979"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}