It’s 6.30 pm in a busy children’s Emergency Department. Archie, 19 months, presents with his mother and grandfather. At triage, his mother says he hasn’t been well for a couple of days but today he has gone off his food and has had a high temperature.
She hasn’t been able to reduce it with paracetamol. During an earlier visit to the GP she was told it was likely a viral illness.
Assessment demonstrates a flushed child, a little clingy with mother but interested in his surroundings. He has a temperature of 38.9 degrees, a RR of 42 and a heart rate of 165. His capillary refill time is 2s centrally but his peripheries feel a little cool. The nurse gives him a dose of ibuprofen and he is placed in a cubicle awaiting medical review
10 minutes later there is a scream from the cubicle. The grandfather rushes out to say, “He’s fitting, he’s fitting!” Available doctors and nurses rush into the room. Archie is having a general tonic-clonic seizure, both arms and legs are jerking and his eyes are rolled back. He does not appear cyanosed. One of the doctors supports his airway, he is breathing adequately, while another performs an examination. His mother is in tears holding onto his hand. His grandfather gets angry saying he had told the GP if he didn’t do anything about the fever then he might have a fit like his son used to.
Time passes, guidelines at this institution are as per A.P.L.S. As a nurse draws up some buccal midazolam, a senior paediatric trainee mulls over the next steps. It’s a couple if minutes into the fit. Do they presume it won’t finish – cannulate regardless in case the midazalom (if needed) doesn’t work. The child has no airway or respiratory comprise. They don’t appear shut down, there is no obvious rash suspicious of meningococcaemia. There is a clear vein on the dorsum of the right hand….
Grandfather challenges the team about why they are just standing there doing nothing. A member of staff is assigned to explain the situation to the mother and himself. A colleague cannulates as the clock ticks on.
At five minutes the generalized convulsion continues. Glucose has been confirmed as normal. Cardiovascular and respiratory status remain acceptable. Oxygen is applied via a wafted mask although sats have never dropped below 98%. A dose of lorazepam is given. There is a tense wait….
Further examination has revealed little else. Pink eardrums, but neither bulging. No added sounds to the chest. Oropharynx impossible to visualize.
There is no effect to the medication. The seizure continues, jerks become less frequent but slightly more pronounced. Sats drift to 95%, no airway intervention is deemed necessary. Bloods taken during the cannulation reveal no acideamia, a normal lactate and a white cell count of 11.9. Electrolytes by near-patient testing are normal.
The clock reaches ten minutes. Archie is still fitting. The mother remains visibly distraught and grandfather’s frustration is increasing.
A story such as this will be played out, with variations but to a common theme, in emergency departments around the world. The focus of the blog was inspired by this tweet though.
and my response, prompted by (something I did already know) the AAP guidelines on febrile convulsions stating a simple convulsion can be up to 15 minutes in duration.
The evidence is pretty clear that the actual incidence of serious bacterial infection in febrile convulsions isn’t high (in fact rates of meningitis even in complex febrile convulsions are pretty low if there aren’t any associated signs of disease). But the conundrum is this:
The convulsion is happening in the hospital. You are being watched by your peers, colleagues, and parents. 2 minutes, let alone 5, and heaven forbid 10 minutes (the time between the first and second dose of a benzodiazepine in a paediatric seizure) feels like a lifetime. (As an aside 10 minutes is apparently Stairway to Heaven plus two minutes according to @NodakEM) So not only is there the need to wait and do nothing before you commence terminating the seizure, having seen it then go on for 10 minutes are you brave enough to wait for the full 15 before commencing any antibiotics not yet knowing this is definitely a febrile convulsion?
I raise this as an observation of a real dilemma. It’s not mentioned in textbooks, taught on advance life support courses and certainly not mentioned in journal clubs. Doing nothing is sometimes really hard….
Those who have balanced the need to lead a team and placate a parent in these situations will have their individual approaches to being proactive while time passes. A great simulation scenario would be to act through what you can do in the 5-10minutes before active interventions take place. I hope this blog starts debate on other situations that are recognized but not really encapsulated by other resources. Another reason demonstrating #FOAMed is leading the way.