Loaded with phenytoin, 20 minutes later stopped fitting.
Further clinical assessment. Only responding to deep painful stimuli (AVPU), pupils size 7 slowly reacting, normal fundi. BP 140/85, HR 90
Case History
4 year old girl brought by ambulance following a prolonged seizure, which had begun 40 minutes earlier. Parents found her in the living room shaking all of her body and unresponsive to their voices. Immediately called 999 ambulance. The paramedic team have given diazepam rectally and she is on 100% oxygen.
Non-specifically unwell for several days with a cold and behaving quite irritably. Fever for 24 hours and vomited during the day - her parents have been giving her paracetamol. She has never had fits before and there is no family history of seizures.
Taken immediately to ED Resuscitation: Status epilepticus ? cause possible infection. ED SHO assessment immediately:
Airway self-maintained but guedel airway in situ inserted by paramedics. 100% oxygen with saturations of 100%. Air entry equal bilaterally. Well-perfused centrally.
Generalised tonic clonic seizure continuing. No rashes seen.
Observations: Temp 39.5, BP 130/80 (difficult to measure), Pulse 100, RR 56.
Blood sugar 7.1.
Immediate intervention
i.v. access obtained X 2, bloods taken including blood cultures.
i.v. ceftriaxone and acyclovir commenced
Given IV lorazepam X 2 0.1mg/kg, failed to stop seizure
QUESTIONS ON CASE 9
Q 3 of 8: Are there signs of raised intracranial pressure?
Yes No
CORRECT : The patient has a depressed conscious level, which may partly be due to the anti-convulsants, raised BP with borderline low heart rate. The pupils are dilated.
Patients with RICP may have prolonged capillary refill time and a mild metabolic acidosis. If these signs are present in a patient with a normal heart rate or bradycardia, and a normal or high blood pressure, then they are not due to shock.
The diagnosis of raised intracranial pressure is a clinical one:
Routine CT scanning is not indicated in patients with meningitis as CT scans are not sensitive in picking up signs of RICP 3132. It is dangerous to put a child with fluctuating conscious level into the scanner without securing the airway first.
