Medical Emergencies

1. Medical Emergencies

2. Objectives • Describe the potential causes and outline the management of seizures in children • Discuss the implication of fever as a presenting sign in children • Discuss common causes of altered level of consciousness (ALOC) • List signs and symptoms of hypoglycemia and hyperglycemia, and outline management

3. 3-year-old child • You are called to the home of a child who has had a fever for one day • Prior to your arrival she experiences a single generalized seizure followed by confusion

4. Appearance Drowsy, but interacts Work of Breathing Normal Circulation to Skin Normal color 3-year-old child

5. Initial Assessment • Airway - Open, no stridor • Breathing - RR 25 breaths/min, clear breath sounds • Circulation - HR 115 beats/min; skin warm to the touch; normal capillary refill; BP 105/65 mm Hg • Child begins to have another seizure What are your treatment and transport priorities?

6. Treatment Priorities • Place oxygen 15L/minby face mask • Suction airway as needed • Consider placing a NP airway • Be ready to support breathing with BVM ventilation • Transport

7. Treatment Priorities BLS treatment priorities plus… • Assess serum glucose, treat if < 60 mg% • Administer a benzodiazepine • Diazepam - PR or IV • Midazolam - IM or IV • Place patient on a cardiac monitor and pulse oximeter • Transport when seizure stops

8. Child receives 0.5 mg/kg (6 mg) diazepam PR • Child stops seizing and respiratory rate drops to 4 breaths/min Should the child be intubated? Should you transport immediately?

9. Respiratory depression is the most common complication of seizures and can occur after benzodiazepine administration. • Place a NP airway and begin BVM ventilation. • Transport and continue BVM en route to the emergency department.

10. Seizures in Children • Epilepsy: seizure disorder defined by > 2 afebrile seizures • Status epilepticus:  2 seizures without regaining consciousness, or prolonged seizure • Febrile Seizure: seizure associated with fever in an infant or child 6 months to 5 years of age and without other cause What are some of the possible causes of seizures in children?

11. Etiologies of Seizures What is the significance of fever in this patient?

12. Fever • Fever may indicate a serious infection in the blood or central nervous system. • Ominous signssuggesting a serious cause: bulging fontanelle, stiff neck, prolonged CRT, purplish rash • Newborns and young infants may have nonspecific symptoms of serious infection such as fussiness, poor feeding, or decreased activity.

13. Fever • Temperature < 105º F is not harmful and does not cause brain damage. • Treatment: Body substance precautions, passive cooling • Transport priorities: If initial assessment is normal, do focused history and physical exam, and detailed physical exam on scene; if initial assessment is abnormal, treat en route to the hospital

14. 4-year-old child • You are dispatched to the home of a child “not acting right”. • She was recently diagnosed with diabetes and is on insulin.

15. Appearance Disoriented Work of Breathing Normal Circulation to Skin Normal color 4-year-old child

16. Initial Assessment • Airway - Open, no stridor • Breathing - RR 30 breaths/min, clear breath sounds, SaO2 96% • Circulation - HR 140 beats/min; skin moist and warm; CRT 2 seconds; BP 95/65 mm Hg • Disability - AVPU=V, normal pupillary response to light • Exposure - No sign of trauma

17. What are the potential causes of this child’s ALOC?

18. Alcohol • Trauma, temperature Epilepsy, endocrine, • Infection electrolytes • Psychogenic, poison Insulin • Shock, space occupying Opiates, overdose lesion, subarachnoid Uremia hemorrhage ALOC Etiologies

19. Look for an identifying bracelet or other information that could give a clue to the cause of ALOC What are your initial management and transport priorities? ALOC Assessment

20. Treatment Priorities • Position the head and open the airway • Provide oxygen 15L by facemask or as tolerated • Consider placement of a NP airway • Prepare to perform BVM ventilation as needed • Consider immobilization of the spine • Transport after airway management is initiated

21. Treatment Priorities BLS priorities plus... • Check blood glucose level • If < 60 mg%, give D50W 1 ml/kg bolus via IV • If IV not obtainable, give glucagon 1 mg IM • Consider naloxone

22. Blood glucose value 30 mg% • Child becomes alert and interactive after D50W IV • Perform focused history and physical exam, and detailed physical exam on scene • Patient transported to the emergency department for further care

23. Hypoglycemia • Serum glucose < 60 mg% in an infant or child and < 40 mg% in a newborn • Common etiologies: • Starvation or sepsis • Too much insulin • Intoxication (alcohol or other drugs) • Metabolic defects • Signs and symptoms may be subtle • Lethargy, pallor, sweating, tachycardia

24. Hyperglycemia • Hyperglycemia can lead to dehydration and ketoacidosis • Symptoms include increased thirst and urination • Signs of shock may be present

25. Conclusion • Airway and ventilatory support are the most important aspects of seizure and ALOC management. • Fever itself will rarely harm a child but may be a sign of a serious infection. • Check blood glucose level in all children with ALOC.