BY STEVEN KANARIAN
At 2:24 p.m. on a Sunday afternoon, paramedics and an engine company are dispatched to a “child not breathing.” Dispatch reports a hysterical female caller reporting her seven-year-old son unresponsive and possibly not breathing. Arriving responders find an approximately seven-year-old boy lying on the living room couch. The patient’s head and shoulders are draped over the arm rest, and he barely notices the firefighters entering the room despite the noise of their equipment and radios. The patient has a vacant stare, is very pale and diaphoretic, and barely responds to painful stimuli.
- Paramedic Miguel: What happened?
- Mother: He’d been feeling ill since 11:00 this morning. All of a sudden, he had a seizure. It scared the life out of me!
- Miguel: Does he have a history of seizures?
- Mother: No, never. He has mild asthma, but no other problems.
The crew places the patient on oxygen via nonrebreather mask, obtains a set of vitals, and places ECG electrodes. With a little stimulation, the patient’s respirations increase from 10 to 16.
Bob from the CFR engine company reports the vitals: “BP 150/100, 124 and regular on the pulse, 16 and shallow on the resps; he responds to stimuli but is disoriented, skin warm and moist, pulse ox is 94 percent.” Bob puts a stethoscope to the boy’s chest, “clear and shallow bilaterally.”
- Miguel (to mother): What did the seizure look like?
- Mother: His head went back, and his arms were shaking up and down. (She demonstrated how her son’s arms were positioned during the seizure. Her reenactment resembled classic decorticate posturing, with arms flexed and fists rotated inward.)
- Chris (Miguel’s partner): How long did the seizure last?
- Mother: About three minutes.
- Chris: What was he doing before he got sick?
- Mother: He was playing video games all morning. He stopped at 11 when he didn’t feel well and took a nap.
- Chris: Has he ever had seizures before or felt ill while playing video games?
- Mother: No, he plays those games all the time.
- Miguel (to Chris): What could cause a first-time seizure in a seven-year-old with no neuro history?
- Chris: Maybe trauma or an overdose.
- Chris (to mother): Could the boy possibly have taken any medications or poisons?
- Mother: No, I was watching him all morning, and he took his nap right here on the couch.
- Chris: Does he take any medications, ma’am?
- Mother: An inhaler for his asthma; I think it’s called albuterol.
- Chris: Is he treated for any other medical problems?
- Mother: No.
- Chris: Any allergies to medications?
- Mother: No.
- Chris: Any recent injuries or falls?
- Mother: No.
As Chris begins to gather equipment to start an IV, Miguel discusses the differentials for a first-time seizure in a healthy child. Thinking back, Miguel reviews the acronym OPQRSTOnset, Pain duration (if pain is present), Quality, Radiation, Severity, and Timeto ensure they have obtained a complete history of the present illness (HPI), and pertinent positives for seizures.
Considering past medical history (PMH), Miguel reviews the mnemonic device SAMPLESigns and symptoms, Allergies, Medications, Past medical problems, Last oral intake, and Events leading up to the seizure.
- Miguel (to mother): What was the last thing he ate or drank?
- Mother: He had breakfast at about 7 a.m., but he only ate toast.
- Miguel (thinking of past medical problems): Ma’am, when was he in the hospital last?
- Mother: Three weeks ago for nasal polyps.
- Miguel: Did he stay overnight or just go to the emergency room?
- Mother: He went in for surgery to remove some nasal polyps and ended up staying there for five days.
- Miguel: Do you have any of the discharge paperwork or instructions?
- Mother: Yes. (She digs the paperwork out of a pile in the kitchen table.). Here it is.
Miguel scans the discharge paperwork given to patients following surgery, information about nasal polyps and a prescription for Augmentin® (amoxicillin/clavulanate).
- Miguel (to mother): Did you fill this prescription?
- Mother: No, I don’t have insurance, and they wanted $130 for those pills.
- Miguel: Ma’am, Augmentin® is an antibiotic, which prevents infection. Your son may have an infection from his surgery.
- Miguel: Thank you, Ma’am.
- Miguel (calling out from the kitchen): Chris, Lieutenant, have everybody wear masks and gloves; he may have encephalitis or meningitis.
- Chris: Meningitis? Where did you pull that one out of, Miguel?
- Miguel: He was admitted for nasal polyps and never received antibiotics on discharge. It could be an infection, encephalitis, sepsis, or meningitis.
- Lieutenant: Good job. Gloves and masks, boys, and let’s bag the gear coming out for decon at the station.
Chris and Miguel place an isolation mask over their patient’s nonrebreather, don their N-95 masks, and start an IV of normal saline.
- Chris (performing a finger stick blood glucose): His sugar is 48; let’s get rolling. We can give him some dextrose during transport.
When they sit the child upright for transport, he vomits yellow bile. En route to the hospital, the patient receives 0.5 grams per kilogram of 25 percent dextrose IV; no improvement. When the D25 is repeated, there is no change in the child’s mental status. Chris asks the child if he has any neck pain; the boy shakes his head weakly, indicating no. Palpation of the posterior neck and flexing of the legs do not provoke pain; pain would indicate meningeal irritation from meningitis.
On arrival at the hospital, Miguel gives a presentation, including HPI, pertinent positives, PMH, and vitals. The Emergency Department staff places the patient on meningitis isolation precautions. After a 10-day stay in the hospital on intravenous antibiotics, the boy was discharged neurologically intact.
Many, if not most, of our responses to calls for seizures involve patients with diagnosed epilepsy. EMS providers tend to regard seizure calls as routine responses and rely on standard diagnoses of epilepsy or febrile seizures. This response, involving a lethargic seven-year-old boy following a first-time generalized seizure, is a significant incident that is sure to raise an eyebrow of even the most experienced fire department responders.
Begin pediatric patient care with a “doorway” assessment. When accessing a scene involving a pediatric patient, visualize the child to determine if he is conscious and alert or lethargic and apathetic. Children who fail to respond to the arrival of the fire department very likely have a serious pathology altering their mental status.
ASSESSMENT/MANAGEMENT OF PEDIATRIC LIFE THREATS
The Pediatric Assessment Triangle (PAT) (Figure 1) is a standardized assessment tool for initial evaluation of the pediatric patient. The PAT consists of assessing the child’s appearance, breathing, and circulation. Evaluating appearance includes assessing the patient’s muscle tone, mental status, interaction with the caregiver, consolability, gaze, and speech. A quiet, lethargic child is a patient in need of immediate resuscitation. Evaluating breathing involves assessing the patency of airway, oxygenation, and ventilation. Assess airway by looking at body position, chest excursion, respiratory rate and effort, and lung sounds. Sniffing position and tripod position are hallmark signs of respiratory distress. Grunting and paradoxical respirations are ominous signs of respiratory failure. Assessment of circulation evaluates the adequacy of cardiac output and perfusion to vital organs. To assess circulation in a pediatric patient, observe the skin color, end organ perfusion, and level of consciousness. Mottled skin, restlessness, and oliguria (low urine output) are signs of circulatory failure.
Using the PAT to gain an initial impression of the pediatric patient’s condition gives prehospital providers a tool for rapidly sizing up a child’s potential life threats.
Once threats to life have been identified and treated, we can obtain a thorough HPI. A systematic HPI and physical are the keys to diagnosing the presenting medical problem and determining the correct course of treatment. Systematic collection of patient information leads to quality care. Most presenting problems are easy to determine and are accepted at face value. Thorough prehospital care providers consider the obvious diagnosis and then dig deeper to search for and consider other possible diagnoses. The most interesting diagnoses, like this case of meningitis in a seven-year-old with a seizure, are made with a careful history and consideration of possible alternative diagnoses. Without a thorough history and considering the possible causes of the child’s seizure, the firefighters, paramedics, and hospital staff would have been unnecessarily exposed to meningitis and would likely have required antibiotic prophylaxis. Depending on the infectious agent found, the EMS equipment could well have cross-infected other patients on subsequent calls or the crew members themselves. The case in this article was diagnosed using the information about the patient’s recent surgery, elicited from the HPI, coupled with knowledge about causes of altered mental status.
PRESUMPTIVE DIAGNOSIS USING “AEIOU-TIPPS”
The differential diagnosis of altered mental status (AMS) in a patient can be facilitated by using SAMPLE for the PMH and the acronym AEIOU-TIPPS (Table 1) to review the causes of AMS/seizures.1 Systematic assessment, HPI, and PMH are essential to accurately and rapidly diagnose your patients. AEIOU-TIPPS is yet another tool to help you systematically consider causes of AMS/seizures in addition to the first impression you form on-scene. In the case presented, consideration of all causes of AMS resulted in better patient care and increased safety for responders and hospital staff.
Memorize AEIOU-TIPPS or, more practically, laminate and mount it on your clipboard or med bag for quick reference on-scene.
FEBRILE SEIZURES: THE FAMILIAR DIAGNOSIS
Fire EMS providers may make a presumptive diagnosis of febrile seizure in children with a history of illness and rapid increase in fever. Febrile seizures occur in two to five percent of children under six years of age; most occur between 18 months and six years of age. In practice, seizures should not be diagnosed as febrile until other causes can be excluded,2 including uremia, infection, brain or spinal cord lesions, and electrolyte imbalances.
In this case, providers presented with a seven-year-old male status post seizure, fever was absent, and the patient was more than six years old, making a diagnosis of febrile seizure unlikely. Febrile seizure may be a dangerous assumption in the prehospital pediatric patient, especially in the presence of AMS. Consider all possible causes of seizure before making a definitive diagnosis of febrile seizure.
A MORE SERIOUS PROBLEM: MENINGITIS
In this case, the recent history of nasal surgery and lack of follow-through with antibiotic coverage were key elements alerting firefighters to the possibility of meningitis. Meningitis is an illness involving inflammation of the tissues covering the brain and spinal cord. Viral or “aseptic” meningitis is the most commonly seen and is caused by one of several types of viral infections. In the United States, annual hospitalizations for viral meningitis range from 25,000 to 50,000 cases.3 Bacterial meningitis is far more severe than viral forms and can lead to coma and death following a rapid onset. One such bacterial form is staphylococcal meningitis, which can occur following a penetrating head wound or neurosurgical procedures.
Meningitis occurs when an infection breaches the natural protection of the central nervous system. The blood supply of the meninges lies adjacent to the venous system of the nasopharynx, mastoid process, and middle ear. When an organism eludes the immune system and enters the cerebral circulation through one of these openings, infection spreads quickly through the subarrachnoid space.4 Meningitis can occur with or without neck pain. Even when present, neck pain may be difficult to assess in young children or in patients with AMS. Nuchal rigidity, or stiffness of the neck with movement, may not be present in younger children with meningitis. Verbal children with meningitis often complain of headache and neck pain. Symptoms often are accompanied by vomiting in the younger pediatric population.
Meningitis can have a gradual or sudden onset. Gradual onset meningitis is preceded by several days of lethargy, fever, GI and respiratory symptoms, and increased irritability. Meningitis with rapid onset often will present with shock, petechiae (small pinpoint red spots on the skin), purpuric spots (large purple or black spots), tendencies toward excessive bleeding, and reduced levels of consciousness. Without treatment, death frequently occurs within 24 hours.
Physical symptoms of bacterial meningitis depend on the age of the patient, underlying medical conditions, and the causative organism. A respiratory illness or sore throat often precedes the more characteristic symptoms of fever, headache, stiff neck, and vomiting. Kernig’s5 and Brudzinski’s 6 signs appear in about half of patients. In children, the presence of nuchal rigidity is a more reliable indicator of meningeal irritation than Kernig’s or Brudzinski’s sign.To detect nuchal rigidity in older children, ask them to sit upright and touch their chin to their chests. Persuade younger children to touch their chin to their chest by following a small toy or light beam.7 Although adults may become desperately ill within 24 hours, children often progress more quickly. Seizures occur in about 30 percent of patients. In patients two years of age and older, changes in consciousness progress through irritability, confusion, drowsiness, stupor, and coma.8
Management of a patient with meningitis begins with proper personal protective equipment (PPE) (gloves, mask and gown, or BBP ensemble). In the management of a critical pediatric patient with suspected meningitis, attention to the PAT and life-saving interventions such as airway maintenance, suctioning, oxygenation, and fluid resuscitation are essential. In the AMS child, administration of dextrose (0.5 grams per kilogram) will help establish normal glucose levels. In the event of seizure activity, administer anticonvulsants (such as diazepam or midazolam) to stop seizure activity. Monitoring the airway and ventilation, especially following benzodiazepine administration, is critically important. Capnography is an excellent early warning tool for hypoventilation in any patient.
Considering the progression of events, it would seem that a call for new onset seizures in any patient should be considered a serious call. This article reviewed the importance that a detailed history of present illness and a thorough past medical history can have in improving accuracy of the diagnosis. There is clear danger not only to the patient but potentially to the crew, transport personnel, and hospital staff from incorrectly assuming a patient has had a febrile seizure. Proper PPE for seizure patients with continued AMS is crucial for protecting firefighters, family members, the public, and other health care providers. Febrile seizures are isolated seizures that typically occur in children between 18 months and six years of age who have a fever. Febrile seizures can only be diagnosed after ruling out all other causes, including infection, which cannot be definitively done in the prehospital environment. Use of the AEIOU-TIPPS acronym is helpful for systematically considering all possible causes of AMS. By being diligent in detecting life threats, eliciting a thorough history, and considering all the causes, we can best help our patients and better protect ourselves. The discerning and outstanding prehospital provider will always think, “It looks like this is the problem; what else should I consider?”
1. Caroline, Nancy. Emergency Care in the Streets (Sudbury, Mass.: Jones and Bartlett Publishers, 2008). Book 3: 41-42.
2. Merck Manuals online Library. “Febrile Seizures.” http://www.merck.com/mmpe/sec19/cH283/cH283c.html, accessed 08/13/2008.
3. Centers for Disease Control and Prevention. “Viral (“Aseptic”) Meningitis FAQs” http://www.cdc.gov/ncidod/dvrd/revb/enterovirus/viral_meningitis.htm; accessed on 08/13/2008.
4. Aehlert, Barbara. Comprehensive Pediatric Emergency Care. . (St. Louis, Mo.: Elsevier/Mosby, 2005).
5. Kernig’s sign: An indication of meningitis in which complete extension of the leg at the knee is impossible when the individual lies on his back and flexes his thigh at a right angle to the axis of the trunk. The American Heritage® Medical Dictionary, © 2007, 2004, Houghton Mifflin Company, online.
6. Brudzinski’s sign: A physical sign of meningitis, evoked by passive flexion of one leg resulting in a similar movement on the opposite side, or if the neck is passively flexed, flexion occurring in the legs. McGraw-Hill Concise Dictionary of Modern Medicine, © 2002, online.
7. Bates’ Guide to Physical Examination 9th edition. Bickley, Lynn S. and Peter G. Szilagyi. (Lipincott Williams & Wilkens, 2007). 751.
8. Merck Manuals online Library. “Acute Bacterial Meningitis.” http://www.merck.com/mmpe/sec16/cH218/cH218b.html; accessed on 08/13/2008.
STEVEN KANARIAN, MPH, is the instructor coordinator for the LaGuardia Community College Paramedic Program in Queens, New York. He is also a lieutenant with the Fire Department of New York, EMS Command, and chairs the National Association of EMS Educators (NAEMSE) Research Committee.