‏ intro ‏ case ‏ background ‏ making diagnosis ‏ pathophysiology ‏ Management Principals ‏ Management Algorithm ‏ Development ‏

case1
case2
case3
case4
case5
case6
case7 case8 case9

CASE HISTORY


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


  help

QUESTIONS ON CASE 9


     Q 3 of 8: Are there signs of raised intracranial pressure?

YesNo <incorrect

INCORRECT : 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.
Further Information

Clinical signs of raised intracranial pressure

Children with meningitis are at risk of developing RICP (see pathophysiology of RICP).

Signs of RICP are:

  • Falling or depressed conscious level
  • Abnormal posturing; decorticate or decerebrate
  • Dilated pupils or unequal pupils
  • Focal neurology
  • Bradycardia and hypertension
  • Abnormal breathing pattern
  • Cushing’s triad: slow pulse, raised blood pressure and abnormal breathing pattern – late sign of RICP
  • Papilloedema is a late sign, its absence does not mean there cannot be any RICP

    Note: Health care workers are encouraged to wear masks when carrying out procedures which may result in exposure to infectious respiratory droplets, for example during resuscitation46.

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:



LOOK IT UP


New01.jpg
New02.jpg
New03.jpg
New04.jpg




New05.jpg




New06.jpg
New07.jpg
New08.jpg


New09.jpg



New10.jpg




New11.jpg