Clinical solution: A 2-month-old having a seizure
You responded to a day care center at a local preschool; did you get the treatment steps right?
It is estimated that in the United States between 25,000 and 40,000 pediatric patients experience a first-time seizure every year. More important to EMS providers than the overall number of seizures each year is determining how best to manage these patients and what, if any, underlying cause can be treated. In Henry’s case, he presents to EMS following his seizure obtunded (lethargic), but maintaining an adequate airway. He appears to be oxygenating poorly, but improves with the application of blow-by oxygen. Since the seizure appears to have stopped, perhaps the nature of the seizure can provide a clue to the underlying cause.
The initial patient size-up
Seizures are classically thought to be like those shown on TV or in the movies: violent tremors involving the whole body. While that characterizes a subset, known as tonic-clonic seizures, absence or focal seizures may be seen as well. Rather than being full-body in nature, Henry’s seizure was reported to involve only his right arm. That abnormal seizure presentation along with the fact that Henry is African American and any additional history you may have obtained from his family may indicate that his seizure is a symptom of his underlying condition.
Common causes of seizure in children are hypoglycemia and fever. Hypoglycemia is a simple cause to rule out and, in some areas of the United States, use of a glucometer is being adopted into the EMT scope of practice. While hypoglycemia can be reversed with oral glucose, care must be exercised based on the age of the patient, his level of consciousness and his ability to self-administer the glucose paste or beverage.
Febrile seizures are common, but are found in patients with elevated fever. Henry’s rectal temperature of 99.0 Fahrenheit is considered to be in the “normal” range as rectal temperature tends to run higher than an oral temperature.
Stroke in children
While often thought of as a disease of old age, stroke can occur in children as well. In fact, the risk of a stroke occurring in the first 19 years of life is roughly five in 100,000 each year. Stroke in young patients is sometimes hemorrhagic; the result of trauma or abuse. There are several additional causes of both hemorrhagic and ischemic stroke to be aware of. In addition to traumatic injury, for example, hemorrhagic stroke may be caused in pediatric patients by malformation of the blood vessels in the brain, resulting in an increased risk of an aneurysm which may rupture.
In adults the risk factors for ischemic stroke are well documented and well known to both in-hospital and pre-hospital providers. In pediatric patients, however, there are a multitude of risk factors for ischemic stroke which makes the underlying cause of a patient’s symptoms especially difficult to pinpoint. Sickle cell disease and heart disease are the two most common risk factors for stroke in young patients.
Sickle cell disease is an inherited blood disorder in which a hemoglobin abnormality results in crescent moon-shaped red blood cells. Because these cells are abnormally shaped, they have a tendency to collect in the blood vessels increasing the risk of stroke and other acute medical conditions. In the United States, sickle cell disease disproportionately affects the African Americans. In young patients of African American descent presenting with abnormal neurologic findings parents and caregivers should be asked if the patient (or any relatives) have a history of sickle cell disease.
Children experiencing a new-onset of stroke may have very different symptoms than those commonly associated with adult patients. In especially young patients, the first sign of a stroke may be a focal seizure involving only one arm or leg. Since the symptoms in children are different than those in adults, a delay in recognition of symptoms and subsequent treatment may occur in children demonstrating stroke-like symptoms.
Treatment options for pediatric patients experiencing stroke have not been subjected to randomized controlled trials but there are options which have emerged through case studies and case series. It appears that thrombolytic therapy may be safe and effective in cases of ischemic stroke though dosing guidelines are not well established. For patients with sickle cell disease, periodic blood transfusion may reduce the risk of subsequent strokes which occur in roughly 50 percent of sickle cell patients who have a first stroke.
EMS care for these patients is largely limited to supportive therapy and recognition of risk factors through thorough history-taking. For sickle cell patients suspected of a stroke, fluid resuscitation to correct dehydration may alleviate some of the symptoms.
Assessment and treatment of the patient
After you complete your initial assessment of Henry, your company officer reports that she has been able to reach Henry’s mother on the phone. You explain what you have found during your assessment and obtain an additional history from Henry’s mother. When asked about sickle cell disease, she reports that she and her husband have a family history of the disease though neither has the disease themselves.
When the ALS unit arrives, you relay your report and after reassessing Henry the paramedic starts an IV. Henry has slightly dry mucus membranes so the paramedic elects to give a small fluid bolus. The ambulance crew initiates a Code 3 transport to the local pediatric center.
Where to learn more
Recognition of stroke and early activation of emergency services is what can save the life of a stroke victim.
For more information about pediatric stroke head over to the Children’s Hemiplegia and Stroke Association and the American Stroke Association. For EMS and public education resources see Stroke Awareness sponsored by the National Stroke Association and the American College of Emergency Physicians.
1. Hirtz D, Berg A, Bettis D, et al. Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. Jan 28 2003;60(2):166-75.
2. Roach ES, Golomb MR, Adams R, et al. Management of Stroke in Infants and Children: A Scientific Statement From a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. Stroke. 2008;39:2644-2691.
3. Roach ES, deVeber G, Riela AR, Wiznitzer M. R(2011, May 17). Recognition and treatment of stroke in children. Retrieved from National Institute of Neurological Disorders and Stroke website: http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedings/childneurology.htm