Playtime Peculiarity

[MrBrown]

It's a bright, sunny day; children are running round enjoying recess and all is quiet at the ambulance station allowing for much newspaper reading, sleep catching up on and telly watching.

You are sent to a local primary (elementary) school for an odd job. The teacher reports that one of her students, a seven year old girl, came back into class after recess. The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze.

Although the siezure subsides with intranasal midazolam the girl is deeply unconscious and has vomited profusely. There are no signs of trauma.

BP 90/40
RR 8
PR 40
SPO2 93%
BGL 2.5mmol/l (~50mg/dl)
ECG sinus bradycardia

No history of illness lately the child has been well and nobody in the school or family can think of anything. You are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.

The teacher states she saw the child come out of the bathroom during recess.

 

[Veneficus]

It's a bright, sunny day; children are running round enjoying recess and all is quiet at the ambulance station allowing for much newspaper reading, sleep catching up on and telly watching.

You are sent to a local primary (elementary) school for an odd job. The teacher reports that one of her students, a seven year old girl, came back into class after recess. The child stated she felt unwell and about 10 minutes later became unconscious and began to sieze.

Although the siezure subsides with intranasal midazolam the girl is deeply unconscious and has vomited profusely. There are no signs of trauma.

BP 90/40
RR 8
PR 40
SPO2 93%
BGL 2.5mmol/l (~50mg/dl)
ECG sinus bradycardia

No history of illness lately the child has been well and nobody in the school or family can think of anything. You are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.

The teacher states she saw the child come out of the bathroom during recess.

reply in PM so others may play.

 

[jrm818]

Clear case of simple hypoglycemia, give her some sugar, obtain refusal, back to TV.

What's that - not an interesting enough scenario? Ah well, I guess there must be more to it than that. Here's my whack at it...


I have a lot of questions initially, but a couple of things need to be worked on while we investigate.


Immediate tx: Everything's going a bit slow. She needs some help in the respiration department, and I think I'd call her borderline hypotension and AMS constitutes "symptomatic" bradycarda (although the bradycardia I'm sure is a symptom itself). Try some atropine? Bp is a bit low, but I bet that's at least partially her insufficient HR to blame.

Her sugar is on the low side, but not so low that I'd think it's the source of all her woes. Still, she should get some IV cake frosting.

Questions:

Any chance of getting a temp?

Lung sounds?

Vomit color/consistancy? Food particles in it (has she been eating?)

Pupils? Any posturing? Withdrawal to pain?

no medical problems/allergies?

What did the seizure look like? Tonic-clonic?

Any physical signs of medical problems? Rash, obvious physical oddities, etc.

We don't happen to be near a farm/industrial area do we? She vomited, but is there a lot of other fluid in the airway (salivation?) With the bathroom hint/red herring, and depending on the rest of the assessment, cholinergic symptoms are jumping out at me...


DDx: no strong thoughts yet, so in no particular order:

occult head injury
non-traumatic acute intracranial event
New onset very bad seizure disorder
infection
SLUDGE
something else entirely


Oh, and give her high flow O2

 

[Veneficus]

Clear case of simple hypoglycemia, give her some sugar, obtain refusal, back to TV.

Test taking skills:

When one of the most knowledgable people on the forum posts a scenario, think zebras not horses.

 

[MrBrown]

Any chance of getting a temp?

Normal

Lung sounds?

Coarse, nasty sounding crackles; she has probably inhailed a lot of vomit

Vomit color/consistancy? Food particles in it (has she been eating?)

Watery brown consisting of bits of food (fruit and a partially digested sandwhich) and normal stomatch contents.

Pupils? Any posturing? Withdrawal to pain?

Sorry Brown did not post a GCS ... it is 3.

no medical problems/allergies?

Are acute onset siezures, hypo and unconsciousness medical problems?

None.

What did the seizure look like? Tonic-clonic?

Tonic-clonic siezure that lasted about 5 minutes until quelled with some intranasal midaz

Any physical signs of medical problems? Rash, obvious physical oddities, etc.

No

We don't happen to be near a farm/industrial area do we?

Nope we are in Pleasentville

occult head injury
non-traumatic acute intracranial event
New onset very bad seizure disorder
infection
SLUDGE
something else entirely

None of the above but what is SLUDGE?

Oh, and give her high flow O2

But of course!

Test taking skills:

When one of the most knowledgable people on the forum posts a scenario, think zebras not horses.

Is that a crank pipe in your back pocket mate?

 

[jjesusfreak01]

Uncontrolled menstrual bleeding during early puberty, leading to loss of blood volume and hypovolemic shock. I would expect a lower BP and a higher pulse rate though if that was the case. Maybe this with mitigating factors...some sort of drug use?

 

[MrBrown]

Uncontrolled menstrual bleeding during early puberty, leading to loss of blood volume and hypovolemic shock. I would expect a lower BP and a higher pulse rate though if that was the case. Maybe this with mitigating factors...some sort of drug use?

Brown thinks we have a candidate for the Parathinktheyare award

No drugs.

 

[vquintessence]

SLUDGE: salivation, lacrimation, urination, defecation, GI distress, emesis

parasympathetic overdrive; vroom.


Me needs more time to mull over this scenario...

 

[vquintessence]

Any cleansers or other products in the bathroom? What do the other kids or schoolyard monitors have to say about the pt during recess?

I liked the idea of menstruation initially, but I can't wrap my head around hypovolemia w/o physical signs & vitals to back it up. The decline is too acute even for the "pediatrics hold until they don't" mantra.


My attempt to tack up a poster by using a monkey wrench would be:
SZ secondary to a toxic substance, followed by a nasty case of aspiration and yuckyness. I'm leaning toward acute toxin exposure w/ some nasty neurological/gastrointestinal profiles.

 

[kravturtle]

It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.

 

[Sandog]

Any signs of edema? I sure would like to get a blood pH?

 

[jjesusfreak01]

Brown thinks we have a candidate for the Parathinktheyare award

No drugs.

Hey, I can have a little fun...the problem with scenarios is the EMT-B level ones are way too easy and the brown ones are crazy hard.

It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.

Not a bad idea, snake bites can cause hypovolemia, but my problem with the vitals was the seeming lack of compensation in pulse rate, plus, when snakebites get bad enough to cause hypovolemia, I think there would be obvious visible swelling, but maybe not? That would be the case unless it was a neurotoxic venom and not a histamine inducing venom...we also have to remember this is a Brown scenario, and Brown is a kiwi, so they probably have all sorts of snakes and spiders that we don't have in the US. If not for the normal temp I would have guessed heat injury.

Maybe Brown gave her a ride on the helicopter and she fell out and hit her head, inducing the seizures.

 

[firetender]

My vote is something in the realm of running while eating, a quick inhale and a partial obstruction, perhaps initiating a period of apnea from laryngospasm which brought on seizure activity and unconsciousness. Under such circumstances it would be transient, but vomiting would be likely. Could have been worse; children have been known to go into cardiac arrest from laryngospasm.

 

[CAOX3]

Hmmmmm.

Second pressure please?

Im going with a rough game of red rover come over (The other children will never admit to it because good little children dont play red rover), wacked her melon on the jungle gym somewhere in the hair line, its gone unoticed.

Stokes respirations, dropped her diastolic, she's herniating, boy oh boy its the triad.

Brown get the helicopter and get this young lady out of here.

Prize please.

 

[MrBrown]

Any cleansers or other products in the bathroom? What do the other kids or schoolyard monitors have to say about the pt during recess?

There are no cleaners in the bathroom, they are kept with the creepy loner seemingly disgruntled janitor who spends most of the day alone in his Unibomber style shack, the only place on the schoolyard that seems to defy all laws of nature, physics and mankind.

It's a nice day, right? And they just got back from recess? I'm thinking some sort of snake/spider bite.

Nope

Any signs of edema? I sure would like to get a blood pH?

Blood pH is normal and there is no edema.

the problem with scenarios is the EMT-B level ones are way too easy and the Brown ones are crazy hard.

Maybe Brown gave her a ride on the helicopter and she fell out and hit her head, inducing the seizures.

Man if you think Browns ones are hard you should see some other peoples, like that crazy Ninja fellow ....

No helicopter ride today .... except to the paediatric intensive care centre.

My vote is something in the realm of running while eating, a quick inhale and a partial obstruction, perhaps initiating a period of apnea from laryngospasm which brought on seizure activity and unconsciousness. Under such circumstances it would be transient, but vomiting would be likely. Could have been worse; children have been known to go into cardiac arrest from laryngospasm.

Nope, not that.

Hmmmmm.

Second pressure please?

Im going with a rough game of red rover come over (The other children will never admit to it because good little children dont play red rover), wacked her melon on the jungle gym somewhere in the hair line, its gone unoticed.

Stokes respirations, dropped her diastolic, she's herniating, boy oh boy its the triad.

Brown get the helicopter and get this young lady out of here.

Prize please.

Second pressure with a half litre of saline is 100/60

No traumatic brain injury here.

The pilots are on thier union mandated 15 minute break, its going to take us at least that amount of time to decontaminate and secure an airway, package the patient, remove various small children that have clung to assorted appendages and pieces of clinical equipment and get her to the helichopper.

Perhaps a quick chat to the paediatric intensivest on the magic ambo phone?

 

[Handsome Robb]

I'll bite.

So no to the toxicity, febrile seizure, TBI, airway obstruction, venomous bite, doesn't seem to be compensating.

I was thinking an odd presentation of meningitis, but you said no to infection and with no fever that would be a very odd presentation. Did we ever give her any sugar to see if that helped? With no obvious trauma and a patent IV line it couldn't hurt. Dehydration? What are her skin signs? Pupils? I'm tired so I may have missed them.

Teacher said she saw her coming out of the bathroom during recess...is this recess after lunch? It'd be fast and wicked onset but food poisoning? But again no fever. Some sort of allergic reaction? Anaphylaxis can cause respiratory distress/arrest which can lead to cardiac arrest in peds, which this one seems to have the possibility of heading that way....compensate compensate compensate, crash, but again you said no to laryngospasm/airway obstruction.

We can use the magic ambo phone but I feel like the man in the orange jumpsuit with DOCTOR across the back isn't going to let us get off that easily.

Just a thought though.

 

[Aidey]

Ruptured appendix?

Heck, ruptured ectopic? Hey, crazier things have happened.

 

[MrBrown]

I'll bite.
I was thinking an odd presentation of meningitis, but you said no to infection and with no fever that would be a very odd presentation.

A septic patient can be either hot or cold, they are most often hot but Brown has recalled at least one who was mildly hypothermic and very unwell.

Did we ever give her any sugar to see if that helped? With no obvious trauma and a patent line D25 couldn't hurt. Dehydration? What are her skin signs, unless I missed them.

You could always try a bit of IM Glucagon or seeing as hoe we already have an good patent drip why not try some IV glucose

Teacher said she saw her coming out of the bathroom during recess...is this recess after lunch?

No, this was morning recess. The teacher said she was the child go in and come out a minute or two later.

She has vomited up large amounts of watery , sludgy, off-colour thick yellow/green vomit.

 

[Harvey]

This was one is easy people. What we have here is your typical case of Cooties!

 

[jrm818]

Are acute onset siezures, hypo and unconsciousness medical problems?

Well some people might say that's just a fun Friday night. Maybe this girl is starting the partying early?


I assumed the glucose didn't work. We should try it, but I'd still be surprised if it did any good.

I'm temporarily stumped. After my total strike-out I was liking the toxin (ingested or injected) ideas, but if those are a no-no I'm not sure what we're left with. I do like Aidy's appendix idea (and ectopic, but would be a major shocker at 7 y/o ), but as with all the hypovolemic scenarios I've been wondering how to explain bradycardia, and I wouldn't think of seizure activity typically either.

Still, how is her abdomen? Rigid, distended, normal?
How are her extremities? Cold and pale, or nice and warm with strong pulses? Cap refill? The fluid helped her BP a bit, was she vasodialated before?

Does the fluid change the HR at all? Have we done anything else for the bradycardia? Are we good enough to listen to heart tones?

Meningitis was among my thoughts in initially asking for the temp, and I don't think that a normal temp strictly rules it out, but with no other symptoms and a zonked patient I don't know how we can diagnose that clinically. Plus, the Brown Sphinx said no to infection...

Do we know any more details about her complaint to the teacher? In what way did she feel unwell?

I'd love to call the peds intensivist once we have time and have completed a thorough enough assessment that we have something useful to say other than "girl sick, no know what wrong, me give oxygen and stand on head, nothing better, what now?" At this point, I wonder if this is beyond diagnosing with physical exam and we need some more intense lab testing/imaging.