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 4 of 8: Should a diagnostic LP be done at this point?
YesNo
CORRECT : LP is contraindicated in patients with depressed conscious level or RICP
Further Information
Lumbar Puncture
Lumbar puncture can be important for treatment if the clinical diagnosis is
in doubt particularly, in children who are febrile without a focus. For children
with obvious meningeal symptoms, microbiological confirmation is valuable for
duration of treatment
decisions about prophylaxis and public health management,
follow up care of children who recover with neurological sequelae, and
disease surveillance.
However, LP must not be performed when there are contraindications and should
never delay treatment. With modern PCR techniques, CSF samples may still be
positive after antibiotics have killed the organisms.
Check with a senior colleague if you are unsure.
Before attempting lumbar puncture assess HR, RR, BP, CRT, pupils, rash, fundal examination for papilloedema.
Make sure there are no signs of raised intracranial pressure or shock.
