Pediatric Seizure

[Rialaigh]

You respond to a pediatricians office about two miles away from your local hospital, upon arrival you find a 7yo male patient lying on his side on the exam table. Office staff called when patient had a seizure. Patient was held out of school yesterday due to "cold symptoms" per grandma. Patient has been exhibiting cold symptoms for two to three days, however oral intake has been fine. Doctor states patient was given tylenol for a fever of 101.3 and about 3 minutes later had a grand mal seizure lasting approximately 4-5 minutes, after which he vomited what looks like bile. Patient then had a second seizure that lasted only 30-45 seconds. Dr.s office was unable to give him anything. Patient has no history, meds, or allergies, no signs of allergic reaction to tylenol.

Patient is minimally responsive to painful stimuli at this point, bile in nose and mouth, breathing 18-20 times a minute slightly irregularly. O2 saturation is 96%. Patient placed on heart monitor showing a heart rate in the mid 50's to mid 60's, sinus arrhythmia, patient still unresponsive. 18 gauge placed in patients arm and he didn't bat an eyelash, bgL 108. Heart rate not above 65 at any point.

30 minutes after dropping patient off at hospital patient still only minimally responsive to painful stimuli, heart rate not above 70.

Thoughts on bradycardia post seizure? etiology? anything specific to look for here? I have a hard time believing this was just a febrile seizure with an abnormal body response.

 

[teedubbyaw]

Interesting. What was his BP? Pupils? Doesn't sound like a typical febrile sz. Initially, I'd have considered a vagal response from vomiting. I'd start considering meningitis (herniation, increased ICP). Possibly anoxic brain injury secondary to the sz (very unlikely).

Wild guesses.

 

[Rialaigh]

Bp 114/74

Pupils were equal and reactive but sluggish. The kid didn't track at all when trying to get him to open my eyes and focus on my finger

 

[ERDoc]

This was definitely not a simple febrile seizure. It is a complex febrile seizure based on the description given (second seizure, prolong postictal period). This kid is also out of the typical age range, which is 6mo-5yrs but it is not impossible. My biggest concerns at this point would be meningitis and encephalitis. The heart rate is low and the BP is high for a kid this age so increased ICP is on the ddx also. Any recent travel history?

 

[zzyzx]

Definitely not a febrile seizure. He needs a lumbar puncture and CT. Another thing to consider is toxic ingestion; i.e. beta blocker, among other things