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Medical Emergencies
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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
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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
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3-year-old child
Appearance
Work of Breathing
Drowsy, but
interacts
Normal
Circulation to Skin
Normal color
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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?
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Treatment Priorities
• Place oxygen 15L/min
by face mask
• Suction airway as
needed
• Consider placing a NP
airway
• Be ready to support
breathing with BVM
ventilation
• Transport
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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
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• 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?
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• 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.
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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?
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Etiologies of Seizures
• Fever
• Hypoglycemia
• Head trauma
• Metabolic disorder
• Hypoxia
• Bleeding into brain
• Infection
• Low level anti-seizure medicine
• Ingestion
What is the significance of fever in this patient?
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Fever
• Fever may indicate a serious infection in the
blood or central nervous system.
• Ominous signs suggesting 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.
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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
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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.
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4-year-old child
Appearance
Disoriented
Work of Breathing
Normal
Circulation to Skin
Normal color
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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
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What are the potential causes of this child’s ALOC?
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ALOC Etiologies
• Alcohol
• Epilepsy, endocrine,
electrolytes
• Insulin
• Opiates, overdose
• Uremia
•
•
•
•
Trauma, temperature
Infection
Psychogenic, poison
Shock, space occupying
lesion, subarachnoid
hemorrhage
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ALOC Assessment
• 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?
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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
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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
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• 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
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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
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Hyperglycemia
• Hyperglycemia can lead to dehydration
and ketoacidosis
• Symptoms include increased thirst and
urination
• Signs of shock may be present
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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.
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