A FITTING CHILD
History
Tom is a 4-year-old child known to have epilepsy. He is admitted to the resuscitation room in A&E with a fit. He was born at 26 weeks’ gestation and had a periventricular haemorrhage which has led to moderate learning difficulties. He has had a runny nose, a cough and a fever in the last few days. The coughing sometimes leads to vomiting and his mother states that he has vomited up several of his drug doses in the last few days. He is on sodium valproate and lamotrigine. He has had previous admissions with fits but his mother says this is his longest fit. She has already administered buccal midazolam at home with no effect. No one in the family has had cold sores in the past few weeks.
Examination
Tom is in the midst of having a generalized fit which started 35 min before he reached hospital. His temperature is 40.2C, oxygen saturation is 90 per cent in air, respiratory rate 30/min, heart rate 180/min, blood pressure 105/77 mmHg and peripheral capillary refill 5 s. He has a runny nose and an erythematous pharynx with enlarged but non-pustular tonsils. His chest is clear. He has no neck stiffness or rash. There are no other signs. High-flow (15 L/min) 100 per cent facemask oxygen elevates the saturation to 97 per cent and an intravenous injection of lorazepam terminates the fit after a further 5 min, following which Tom is postictal.
INVESTIGATIONS
Normal
Haemoglobin 11.7 g/dL 11.5–15.5 g/dL
White cell count 24.4 109/L 5.5–15.5 109/L
Neutrophils 19.2 109/L 1.5–8.0 109/L
Platelets 435 109/L 150–400 109/L
Urea and electrolytes Normal
Bone chemistry Normal
Liver function tests Normal
Glucose 7.1 mmol/L 3.5–6.5 mmol/L
C-reactive protein (CRP) 106 mg/L 6 mg/L
Venous gas:
pH 7.26 7.35–7.45
PaCO2 6.8 kPa 4.7–6.4 kPa PaO2 3.1 kPa 11–14.4 kPa
HCO3 19 mmol/L 22–29 mmol/L
Base excess 7 mmol/L ( 3)–(3) mmol/L
Questions • What is the most likely cause of this child’s prolonged fit? • Would you do a lumbar puncture (LP)? • What further treatment is required?
Medicine
The most likely cause is poorly controlled epilepsy. A fever (secondary to an upper respiratory tract infection in this case) can decrease the threshold for a fit in a child with epilepsy. The vomiting of medication would further increase the risk of a fit. There would be no point doing drug levels in this case. The absence of neck stiffness and a rash would go against meningitis. Encephalitis is rare. There is no history of recent herpetic cold sores in the family. Encephalitis is often accompanied by a focal fit or focal neurological signs as well as a diminished conscious level and a fever. An LP should not be performed because of the length of the fit. Although this child’s fit is probably due to his epilepsy, the possibility of meningitis or encephalitis cannot be totally ruled out. He has a very high temperature, poor peripheral perfusion, has had his longest ever fit, has a raised white cell count with a neutrophilia and a raised CRP. An LP would help diagnose meningitis and encephalitis and would identify the organism and its sensitivities. However, it should not be performed if there is a risk of raised intracranial pressure, as it may lead to coning and death. A magnetic resonance imaging (MRI) or computed tomography (CT) scan may need to be performed to help rule out raised intracranial pressure prior to an LP. Furthermore, an LP often does not alter the initial management and can be done the next day if the patient is better, in order to elucidate the diagnosis and help determine the type and length of antimicrobial treatment.
Relative contraindications to a lumbar puncture (reproduced with modifications from APLS manual, agreed by ALSG and Blackwell Publishing 2005):
• Prolonged or focal seizure
• Focal neurological signs
• A widespread purpuric rash
• A Glasgow Coma Scale score 13
• Abnormal posture or movement e.g. decerebrate posture
• An inappropriately low pulse, raised blood pressure and irregular breathing (suggesting impending brain herniation)
• Thrombocytopenia or clotting disorder
• Pupillary dilatation
• Papilloedema
• Hypertension
Intravenous fluids, initially 0.9 per cent saline 20 ml/kg, should be administered to improve perfusion and to help normalize the capillary refill time. Intravenous ceftriaxone, clarithromycin and aciclovir should be administered. Antipyretics should also be given. Clinical progress and an LP when the patient is better will help determine the diagnosis and the necessary treatment. Measuring the blood glucose at the bedside is essential to rule out hypoglycaemia in fitting children. One should never give more than a total of two doses of benzodiazepines, because of the risk of respiratory depression. Status epilepticus is one of the commonest paediatric emergencies and it is important to be familiar with its treatment.
KEY POINTS • A glucose level should always be measured in a fitting child. • A lumbar puncture should not be performed if there is concern about raised intracranial pressure, e.g. papilloedema or coma.
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