# infant seizure



## zzyzx (May 6, 2014)

You are called to an 11-month-old baby seizing. The patient has been seizing for 20 minutes prior to your arrival, and is actively seizing upon your when you walk in. How would you manage this patient? You are out in the country, 1 hour away from the nearest ER.


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## NomadicMedic (May 6, 2014)

Start with a good history, IV access. Blood sugar. Set of vitals. Benzo's to stop the seizure. 

Did I mention get a good history? Oh yeah, get a good history.

It could be as simple as a febrile seizure that mom's freaking out about, could be shaken baby syndrome, could be hypoglycemia, could be… Anything. 

Your job is to manage the kid to definitive care.


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## Medic Tim (May 6, 2014)

DEmedic said:


> Start with a good history, IV access. Blood sugar. Set of vitals. Benzo's to stop the seizure.
> 
> Did I mention get a good history? Oh yeah, get a good history.
> 
> ...




This ^^^ 

Oh and make sure you get a good history.


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## rmabrey (May 6, 2014)

DEmedic said:


> Start with a good history, IV access. Blood sugar. Set of vitals. Benzo's to stop the seizure.
> 
> Did I mention get a good history? Oh yeah, get a good history.
> 
> ...


Yep. This


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## Angel (May 6, 2014)

I've had this exact call with a 1 year old and did pretty much everything that was already mentioned. (O2 but I think that's a given) the patient I had, was RSI'd in the ER because they didn't stop so that's an option if you have it. 
Definetly want to try and figure out the why.


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## Handsome Robb (May 6, 2014)

If he's really been seizing for 20 minutes high flow o2 and 0.2 mg/kg versed IN then what DE said. I'd bet they're hypoglycemic from the seizure.

Did anyone say a good history and physical exam? 

Repeat benzos PRN. If you can't stop the seizure I'd consider flying but that depends on their spin times on if it'd be quicker or not. I'd be hesitant to RSI this kid unless we absolutely had to, I don't have that option here though.


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## TheLocalMedic (May 6, 2014)

Did you remember to get a good history?


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## NomadicMedic (May 6, 2014)

I don't know if anyone mentioned it, but a good history is a decent starting point.


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## burnsmh (May 6, 2014)

I am in training, should I get a good patient history?


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## Rialaigh (May 6, 2014)

Backboard, C Collar, High flow O2, A wallet in the kids mouth so he doesn't bite himself....Oh...and a good history ? :unsure:


No seriously though, History, Airway, BgL, Temperature (If possible, most people with a 11 month old have a thermometer). Benzo's (would prefer IV if kiddo is maintaining his airway and I have time to find a site)

 and

 if the repeat Benzo's do not stop the seizing AND oxygenation is a factor AND flight is not available or time efficient, then I would likely RSI this child after more Medic Backup has arrived prior to attempting a 1 hour transport, would prefer not to have a failing airway for that long with no light at the end of the tunnel for stopping the seizure.


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## zzyzx (May 7, 2014)

The parents tell you that everything seemed to be okay today, but then their baby had two seizures. She had had a febrile seizure a few months earlier, so they thought that these were febrile seizures as well.

The Versed you gave IM has had no effect. Blood glucose WNL. IV attempts unsuccessful. 

No RSI in your protocols. No helicopters. You are an hour from any hospital. The baby is continuing with her tonic-clonic seizure.

How would you continue to manage this patient? I don't have any tricks up my sleeve. I just want to see how some of you guys who've actually experienced this have managed.


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## Handsome Robb (May 7, 2014)

How violent is this seizure? Can we safely get a rectal temp? Any recent illness? History other than the febrile seizure? Complications with pregnancy/delivery? How's the house look? Neighborhood? Any signs of trauma? Any accidents? Parents seem like they're being honest or do they seem evasive? So was it two seizures or one continuous seizure? If it was two did the little tyke regain any lucidity during the break? Total time originally was ~20 minutes so we're probably getting closer to 25-30 by now. 

Lets get a BGL as well, we can do that during a seizure, HR and BP and SpO2 are another story, any cyanosis? If we can't stop the seizure and cyanosis starts to present we may have to try and bag assist them. Also, IO access is warranted if IV access is unobtainable, this is approaching status epilepticus. 

If they're hypoglycemic correct it with 1-2mL/kg D25, if we can get a temp and they're febrile I'd give tylenol, benzos PRN IV or IO at this point, load them and lets go. I'd instruct my partner to use the lights if we started getting held up, also would like a rider if I can get one in case this turns into an arrest. I'm not big on transporting emergent but on a long trip like this if there's traffic it will make a noticeable difference in time and we're also looking at an unsecured airway if we can't stop the seizure activity. I'd have to call at this point as well for orders to titrate my versed since my protocol is 0.2mg/kg IV/IO/IN/IM q5 minutes may repeat once and I have a feeling I'm going to need more than that. I'd ask for the same dosing schedule but no max.


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## Angel (May 7, 2014)

pupils? head injury? shaken baby?
for sure get a temp, BGL came back normal
aggressive airway (bagging if needed) 
cant remember if we got vitals? RR? at this point baby is down to a diaper and id be glancing over to check for any bruises
code 3-depending on terrain and traffic conditions, rider
io 
ecg and spo2

like rob, id have to call for more orders for versed, by io the most i could give is 4mg iv or 6mg IN


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## Handsome Robb (May 7, 2014)

I missed the BGL WNL. Oops.

I still say airway IO, mas benzos and transport with the quickness as much as I hate to say that. I will say I'd like to have everything in place before we leave though. I don't need a bumpy transport making things more difficult on a patient who's already seizing. 

I had a thought on the SpO2. I'd try an ear or a forehead and see if we can get a decent pleth wave, no guarantee though. 

Might consider an NPA but some will probably disagree with me on that one.


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## NomadicMedic (May 7, 2014)

zzyzx said:


> The parents tell you that everything seemed to be okay today, but then their baby had two seizures. She had had a febrile seizure a few months earlier, so they thought that these were febrile seizures as well.
> 
> The Versed you gave IM has had no effect. Blood glucose WNL. IV attempts unsuccessful.
> 
> ...




IV (or IO). Benzos. manage airway. transport.

There's no Para-magic other than that.


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## mycrofft (May 7, 2014)

Cooling PRN?
Does the pt have a med order already? (Call pediatrician).

Let's see the Etilogy Tree:

1. Intrinsic seizure disorder or old head injury) by hx: airway, O2, benzos, transport.

2. Recent head injury by hx and or exam: spinal precaution, airway, benzos, transport.

3. Febrile seizure by hx and take temp: cool, airway, oxygen, benzo prn, transport. 

4. Toxic by hx (meth, carbon monoxide, etc: benzo, airway, O2, transport. Pray.


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## Handsome Robb (May 7, 2014)

I disagree with actively cooling this patient unless they're ridiculously febrile. What causes seizures related to temperature is the rapid change in body temp or "spiking a fever". It can go the same way when reducing a fever. Reduce it too fast and you could cause another seizure if they aren't still seizing. Now if they're broiling their brain then yes, we need to do something.


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## Carlos Danger (May 7, 2014)

Benzos, benzos, and more benzos.

Propofol if you have it.

Bgl and airway management, of course.

I find it can be really hard to get a good history in these situations. I wouldn't spend too much time interrogating the parents. Just manage the patient.


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## OnceAnEMT (May 7, 2014)

Halothane said:


> Benzos, benzos, and more benzos.



I keep hearing this, but don't quite know it yet as an EMT-B. Through research I understand its a GABA promoter and thus makes a good and almost always successful attempt at ending seizures. But how is it administered, and at what dose? I've read it could be muccul, IV, or IM. But I can't imagine putting a line in a seizing adult, let alone a seizing infant. What do y'all do?

Thanks!


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## chaz90 (May 7, 2014)

Grimes said:


> I keep hearing this, but don't quite know it yet as an EMT-B. Through research I understand its a GABA promoter and thus makes a good and almost always successful attempt at ending seizures. But how is it administered, and at what dose? I've read it could be muccul, IV, or IM. But I can't imagine putting a line in a seizing adult, let alone a seizing infant. What do y'all do?
> 
> Thanks!



Check out the RAMPART study with some related links for some interesting info on this subject. 


http://www.ncbi.nlm.nih.gov/m/pubmed/21967361/?i=2&from=/24001080/related

Many protocols, mine included, give an option of IN, IM, or IV Midazolam for active seizure. Unless I already have an IV, I always go for IM instead of IN for seizures.


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## Handsome Robb (May 7, 2014)

Grimes said:


> I keep hearing this, but don't quite know it yet as an EMT-B. Through research I understand its a GABA promoter and thus makes a good and almost always successful attempt at ending seizures. But how is it administered, and at what dose? I've read it could be muccul, IV, or IM. But I can't imagine putting a line in a seizing adult, let alone a seizing infant. What do y'all do?
> 
> 
> 
> Thanks!




It's a lot easier to start a line in a seizing patient than you'd think. When we walk into an active seizure my partner asks fire to toss a mask on then go straight for an IV while I draw up meds. If they get a line first it goes IV if I draw them first it goes IM or IN. I've got tricks for trapping arms safely or you can always ask another responder to control the arm while you start and secure the line. 

Our dose of midazolam (versed) here for seizures is 2 mg q3-5 minutes with a max total of 10mg for adults and pediatrics is 0.2 mg/kg q5 minutes like I stated before. It was kinda buried in my post though so no worries.


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## mycrofft (May 7, 2014)

Robb said:


> I disagree with actively cooling this patient unless they're ridiculously febrile. What causes seizures related to temperature is the rapid change in body temp or "spiking a fever". It can go the same way when reducing a fever. Reduce it too fast and you could cause another seizure if they aren't still seizing. Now if they're broiling their brain then yes, we need to do something.



Yup. Fever is not the demon we once thought it was. Cooling the baby can be like spineboarding and giving O2 to everyone: don't just stand there appropriately, doing something.


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## OnceAnEMT (May 7, 2014)

Robb said:


> It's a lot easier to start a line in a seizing patient than you'd think. When we walk into an active seizure my partner asks fire to toss a mask on then go straight for an IV while I draw up meds. If they get a line first it goes IV if I draw them first it goes IM or IN. I've got tricks for trapping arms safely or you can always ask another responder to control the arm while you start and secure the line.
> 
> Our dose of midazolam (versed) here for seizures is 2 mg q3-5 minutes with a max total of 10mg for adults and pediatrics is 0.2 mg/kg q5 minutes like I stated before. It was kinda buried in my post though so no worries.



Roger that. How does IN (I'm assuming that's intranasular) work with a seizing patient?


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## chaz90 (May 7, 2014)

Grimes said:


> Roger that. How does IN (I'm assuming that's intranasular) work with a seizing patient?



IN=Intranasal

In my experience, not overly well. Like I said, I prefer IM every time given a choice.


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## Handsome Robb (May 7, 2014)

Grimes said:


> Roger that. How does IN (I'm assuming that's intranasular) work with a seizing patient?




Intranasal.

It works well for pedis, not worth :censored::censored::censored::censored: in adults but that's anecdotal. 

I had a kid with complex bilateral congenital hip defects that made him prone to dislocations on top of his severe reduction in mental capacity, gave him 25 of fent IN and he went fry screaming to cooing and blowing spot bubbles in about 5 minutes. Didn't even whine when we moved him.

I've given adults 8-10 times that IN through multiple doses and had zero effect.

I've only given midaz to a pediatric once IN but it did what I wanted it to without repeating the dose. Again, anecdotal.

Just make sure they don't have a runny or bloody nose cause then it won't work.


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## OnceAnEMT (May 7, 2014)

Thanks for the info guys. Yeah, I just imagined the versed becoming the bubble when administered IN  But if it works it works.


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## NomadicMedic (May 8, 2014)

The whole IN debate is purely anecdotal. It may depend on the med concentration, the condition of the patients nares and provider training and expectations.

I've had 5mg/1ml of midaz work like a champ. 5mg/5ml, not so much. 

50mcg of Fent for a tib/fib worked great once, didn't the next time.

Narcan IN works 100% of the time for me. 

Would I start with IN versed on this kid? Probably, while I looked for IV access or drilled an IO.


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## zzyzx (May 8, 2014)

No luck with stopping the seizure with benzos. You don't have Propofol or RSI drugs. No anti epileptics.  You cannot get an accurate Spo2. Nothing else on the Hx and parents speak little English. Baby is continuing to have t-c seizure. Looks pale.  Your company does not provide rectal thermometers 

Again I'm just wanting to see how you guys would handle this call


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## FLdoc2011 (May 8, 2014)

Get thee to a hospital.

So no luck stopping seizures after how much benzos?    Keep them coming and intubate.


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## chaz90 (May 8, 2014)

Yeah, intercept with someone who has RSI capability if they're anywhere in between you and the hospital (still 1 hour away?) and keep throwing benzos at them. Tough call scenario, but at this point EMS treatment options are really quite limited...Keep on driving.


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## NomadicMedic (May 8, 2014)

I think you've reached the endpoint, since you've exhausted all of the options.


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## zzyzx (May 8, 2014)

Yeah I guess I agree. I have never had a call like this but am wondering if anyone has, or one where they had to bag an infant or young ped during a long transport time


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## Rialaigh (May 8, 2014)

zzyzx said:


> No luck with stopping the seizure with benzos. You don't have Propofol or RSI drugs. No anti epileptics.  You cannot get an accurate Spo2. Nothing else on the Hx and parents speak little English. Baby is continuing to have t-c seizure. Looks pale.  Your company does not provide rectal thermometers
> 
> Again I'm just wanting to see how you guys would handle this call



No screwing around after the second round of benzo's, if flights not available and we are an hour from a hospital the kid is getting RSI'd now.


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## NomadicMedic (May 9, 2014)

Rialaigh said:


> No screwing around after the second round of benzo's, if flights not available and we are an hour from a hospital the kid is getting RSI'd now.




I'm assuming you didn't read the whole thread, so you missed the part where he said "no RSI". (Although I'm not sure how you did that, as you quoted his post where he mentioned no RSI)

This is really not a great scenario, The OP just wanted an opinion on "what we would do". We all pretty much said the same thing; benzo's, airway support and transport. I don't know what else he's looking for, since he shut down all other avenues for a more rapid transport via helicopter and advanced airway management with RSI. At this point, all you've got left is "drive fast"


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## Carlos Danger (May 9, 2014)

zzyzx said:


> Yeah I guess I agree. I have never had a call like this but am wondering if anyone has, or one where they had to bag an infant or young ped during a long transport time



Are you REALLY over an hour from the closest hospital, and do you really not have ALS or HEMS available, or was this purely hypothetical? 

If this scenario ever happens, it may not end well for the kid. Continuous generalized seizures for well over an hour can potentially fry a brain pretty good. Especially considering the challenges of providing effective BLS ventilation in a moving vehicle for that length of time. 

I do think it's a good thought exercise to consider these worst-case scenarios. Much of the value in it is understanding that we are limited in what we can do, and sometimes our best efforts will not be enough. You can't save 'em all.

A few folks mentioned RSI and while securing the airway and providing ventilation and oxygenation is certainly a high priority in status epilepticus, it doesn't necessary solve the problem - you very well may still have an imbalance between cerebral oxygen demand and delivery once they stop moving from the NMB's. They need DEEP sedation (+/- NMB) and still need to get to an ED ASAP. I know most of those who replied here understand this, but I figured it was worth underscoring.


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## FLdoc2011 (May 9, 2014)

And really NMB is not needed here and won't help.   

Anticonvulsants, benzos and maybe barbiturates to stop the seizures.   In the hospital we'll just induce basically general anesthesia or something like a phenobarbital drip while monitoring an EEG.


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