Cervical Spine Injuries Module

Cite this article as:
Ronán Murphy. Cervical Spine Injuries Module, Don't Forget the Bubbles, 2020. Available at:
TopicCervical spine injury
AuthorRonán Murphy
DurationUp to 2 hours
Equipment requiredComputer with projector for imaging
  • Introduction and Basics: (10 mins) pre-reading, glossary of terms, anatomical considerations
  • Main session: (2 x 15 minutes) case discussions covering the key points and evidence
  • Advanced session: (2 x 20 minutes) case discussions covering diagnostic dilemmas; advanced management and escalation
  • Sim scenario (30-60 mins)
  • Quiz (10 mins)
  • Infographic sharing (5 mins): 5 take home learning points

EMS – Emergency Medical Services

CSI – Cervical Spine Injury

SCIWORA – Spinal cord injury without radiological abnormality

XR – X-radiography

ED – Emergency Department

NEXUS – National Emergency X-radiography utilization study

PECARN – Paediatric Emergency Care Applied Research Network

GCS – Glasgow Coma Scale

MILS – Manual in line stabilization

MVC – Motor Vehicle Collision 

ATV – All terrain vehicles

NPV – Negative Predictive Value

PEM – Paediatric Emergency Medicine

TBI – Traumatic Brain Injury

NICE – National Institute for Health and Care Excellence, United Kingdom

MRI- Magnetic Resonance Imaging

The incidence of cervical spine injury is low and represents only 1-2% of all paediatric major trauma (1). 

The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column (2-4). Other features also make it susceptible to injury: ligamentous laxity, incompletely ossified vertebrae and more horizontally orientated facet joints (5). 

The incidence of ligamentous injury is thought to be higher in younger, non-communicative children under 3 years of age (6).

The precise location of injury in the cervical spine can be variable across the age range (7-9).

Four injury patterns are common in children with cervical spine trauma:

  • Fracture
  • Subluxation with fracture
  • Subluxation without fracture

Dislocations or subluxations are more common in upper cervical spine injuries and associated with greater morbidity (9). To compare with adults, children are over twice as likely to suffer atlanto-axial injury (8).

Weaker musculature and underdeveloped interlocking bony processes contribute to the subluxation/dislocation and SCIWORA (spinal cord injury without radiological abnormality) type injury patterns we see in children (10). SCIWORA refers to CT and plain film. A lesion may be detected on MRI.

SCIWORA is the presence of myelopathy as a result of trauma with no evidence of fracture or ligamentous instability on imaging. The mechanism relates to the flexibility of the paediatric spine being greater than that of the spinal cord which becomes damaged as it is stretched beyond its limits. Neurological signs or symptoms even if transient must be elicited in the history to make this diagnosis (2). 

Manage the cases below as you would in your own setting using local guidelines and procedures to make this whole exercise as realistic as possible and also to stimulate further analysis and discussion. 

A 13 year old boy arrives in your ED. He came off his bicycle at speed whilst engaged in a downhill mountain racing contest. He was wearing a helmet and protective clothing but hit his head against a tree as he landed. He did not lose consciousness. He describes immediate onset neck pain which now persists. Volunteer ambulance services were supervising the event and treated his pain with paracetamol and ibuprofen whilst preparing him for transfer in full spinal precautions. He is brought into your ED strapped to a spinal stretcher with a hard cervical collar in place as well as head blocks and tape. On handover it is noted that he felt a weird sensation in his right arm at the time of the event which lasted perhaps 3-5 mins and has not returned. The crew found his neck to be diffusely tender on examination.

What features in history and on examination are we concerned about regarding the potential for cervical spine injury?

How do we take handover of these patients and protect them whilst we work up their injury?

Predisposing vulnerability to bony or ligamentous failure: Down Syndrome(T21), Rheumatoid Arthritis, Rickets, Osteogenesis Imperfecta, Ehlers-Danlos Syndrome, Achondroplasia, Marfans Syndrome, Renal osteodystrophy, Klippel Feil disease, Morquio Syndrome, Grisel syndrome.

A high risk MVC is one of the following: Head on collision, rollover, patient ejected from the vehicle, death of another passenger occurred, speed of collision over 88kph (55mph).

Distracting injury is vaguely defined by NEXUS to include burns and long bone fractures etc. It can be refined to mean any substantial injury of the upper torso due to proximity to the cervical spine (14).

As described above (11), the Viccelilo study (2001) looked at the performance of NEXUS in the paediatric subgroup. In 2017 however, Cochrane (2017) found there was conflicting evidence to support use of NEXUS in children and called for additional well designed studies with larger sample sizes to better evaluate this population (15). 

Some points to consider regarding immobilization: 

Where a cervical spine injury is suspected, appropriate immobilization must be achieved. 

Ask the co-operative child to lie still. Apply gentle manual in line stabilisation (MILS) and give lots of encouragement (age appropriate) to minimise movement. The neck should reside neutrally or in a position of comfort for the child. Bear in mind that babies may require a pad or similar thoracic elevation device laid onto the trauma mattress to elevate the torso and preserve neutral alignment of spine due to their relatively larger heads. This will prevent any forced flexion occurring.

While providing MILS and reassurance, we must address pain as a matter of urgency. Immobilisation may increase leverage on the neck in a sore and struggling child.  Once deemed safe to do so (and rapport has been established where applicable), radiolucent blocks and straps can be applied to free up that team member from the task of MILS. As well as helping limit movement, blocks also serve as a communication tool / visual reminder to the team that we are worried about this spine and to handle with care.

Transfer: If coming in by EMS, transfer using scoop from ambulance mattress to radiolucent ED trauma mattress. During transferring manoeuvres, the team leader should ensure that the minimal number of movements and gentle max 30 degree tilts are all that’s needed to get them on and off a scoop stretcher. The leader should also ensure that all team members understand their role and are given adequate prompts prior to any movements being performed “ready, steady, move”. Use the opportunity allowed by tilting to complete your standard assessment of the spine (and the patients back for other injuries or relevant findings). Document appropriately. Sometimes children 6 years old and above (not possible to put on below this age) may come in via EMS wearing cervical collars. These are removed to assess the cervical spine in ED while MILS is being applied and hard collars should not be placed back on as they can have a number of negative effects, particularly with prolonged use (16).Two piece collars are different and are often recommended by spinal specialists as a treatment modality for stable fractures or as a bridge to definitive management. 

A 10 month old girl who was a back seat occupant in a rearward facing baby seat is involved in a head on RTC at 30kph (18mph). The incident occurred in a housing estate. She presents with her Mother who was the restrained driver for review at a mixed Adult and Paediatric ED. You have already assessed and cleared Mum from any serious injury. You now examine her baby who is crawling away from you on the bed saying “mama”. 

Discuss how we need to adapt our assessment to suit younger children. 

Are we worried about this baby and do we want imaging? 

Outside of the factors looked at in the large studies, are there any other items which we should consider important in history and on physical examination for all children? 

The studies we have looked at so far don’t have many children under the age of three years old. We will now explore some which do:

Expert Consensus on factors which are suspicious for CSI (18-21):

  • persistent neck pain
  • child or parent feeds like the child has an abnormal head position
  • difficulty with neck movement
  • fall >1m or 6 steps of stairs or fall from greater than body height
  • hyperextension injury, acceleration-deceleration injury involving the head or clothes-lining (blunt trauma to the head/neck by a stationary object while the patient is in motion)
  • bicycle collision, pedestrian versus bicycle, accidents involving motorised recreational vehicles, horse riding accidents.
  • current or transient neurological symptoms (motor or sensory): weakness, paraesthesia, lightning or burning sensation down the spine or radiating to an extremity
  • neurological symptoms related to neck movement.
  • torticollis or abnormal head position
  • posterior midline cervical tenderness
  • substantial injury to the chest, abdomen or pelvis (one that is life-threatening, warrants inpatient observation or surgery)
  • physical signs of neck trauma such as ecchymosis, abrasion, deformity, swelling, tenderness
  • limited cervical range of motion
  • significant trauma to head or face
  • inconsolable child

Where the child does not have any concerning features on history or examination, we can look at some low risk factors which offer us some reassurance:

  • simple rear end MVC
  • comfortable in sitting position in ED
  • ambulatory at any time since injury
  • no midline cervical tenderness
  • presenting with delayed onset neck pain

In the awake and alert patient with no neurological signs or symptoms who has neck pain or unspecified neck tenderness, NICE Clinical Guideline 176 permits the search for any one low risk factor from the above list.

If one is found, further clinical assessment of the neck, beyond the initial assessment and palpation is performed. 

This comprises asking the patient to perform 45 degree bilateral active neck rotations. If this is tolerated the cervical spine can be cleared clinically. If not, the patient gets imaged. 

Persistent neck pain/tenderness in the posterior midline with normal clinical examination otherwise and normal conventional radiographs requires further evaluation. The same applies even if the patient presents sub acutely (18). This will vary between institutions but may take the form of a referral to the orthopaedic or spinal service followed by MRI or CT. 

Beware the “trivial” injury, especially in younger children. Correlate history with clinical examination. Remember these patients can be more difficult to assess and there exists limited evidence to guide their management. There are cases in children 9 months to 6 years of falls less than 5ft, out of bed, down steps, running, somersaulting which have led to C1-2 subluxations, rotatory subluxation, C2 pedicle fractures, odontoid fractures and neural arch C2 fractures. Examination findings were torticollis, neck pain, limited range of motion neck, refusal to move neck any one or combination of the above on exam but never just neck pain (22).

Beware also of markings on the child’s body from seatbelts or other age appropriate restraint systems. These may indicate extreme flexion of the cervical spine has occurred especially in head on collision (23). 

As always, consider the potential for non-accidental injury in your differential. 

Involve a senior early in the assessment and management of all suspected cervical spine injury children. 

Interpretation of imaging (where it is necessary) and patient reassessment: 

As we have discussed above, plain films are the main imaging tool used to assess the cervical spine in the ED. These must be interpreted by a senior physician due to the inherent challenges involved. 

If imaging is adequate and shows no abnormality in an alert and cooperative patient (or if imaging was not required in the absence of concerning features), reassess for resolution of neck pain post analgesia. Check 45 degrees of neck rotation either side of the midline. If normal, ask if you are satisfied that there isn’t any persisting clinical concern. If they examine well and there is no residual concern, many institutions and the NICE guidelines declare that the spine is now clear. This final clearance step should always be performed with a senior present.

An 11 year old boy is involved in a single vehicle RTA as a front seat passenger restrained in a booster seat. The vehicle slid at 120kph (75mph) and spun out of control demolishing a fence at the side of the dual carriageway and impacting a treeline before being propelled back onto the road. There is extensive damage to the four door saloon and all airbags deployed. The boy’s father was driving at the time and they self extricated by kicking out a front door which was slightly wedged by the distorted frame. They stood by the side of the road awaiting help to arrive. The father states he is fine apart from a few scrapes from broken glass and declines further assessment by Paramedics. The son complains that he now notices neck pain on moving his head backward and forward. EMS reviewed and decided to treat him with full spinal precautions. He arrives in your ED and is assessed as having no evidence of bruising or deformity of the neck and no midline bony tenderness. He has a normal neurological examination. His neck pain is persistent despite ibuprofen and paracetamol given by EMS en route. He is reluctant to move it much.

Do you want to image this child and if so, what imaging do you want to perform?

The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous (24).

To obtain the optimal sensitivity from plain film we need two or more views. The odontoid view is technically difficult to obtain in children less than 5 years old and may not yield much diagnostic information which can’t be obtained on antero-posterior and lateral. 

Many paediatric radiologists do not routinely obtain odontoid views in children younger than 5 years and many more stop after the first attempt is unsuccessful. The fracture that can only be assessed on the odontoid view is the Jefferson fracture (an eponym for a burst fracture of C1) and this occurs with axial loading mechanisms (uncommon below this age). Usually there is an associated head injury which would require neuroimaging (including upper cervical spine in CT) (25).  

In infants and young children, fractures of the dens tend to involve the subdental synchondrosis (naturally weak area of C2), from flexion mechanisms. The resulting anterior tilt of the dens is normally visible on lateral views. 

Adopting a pragmatic approach based on the child’s age and clinical status allowing them to obey commands and open their mouth is the best course of action (26). Safety is paramount and this view can be dangerous as some movement is required of the patient (10).

It is common practice now to minimize the exposure of children, parents and staff to radiation. The neck is a radiosensitive anatomical area and the thyroid gland receives a 100-200 fold higher radiation dose with CT than with the standard three view plain film series. This extrapolates to a 2x higher mean excess risk of thyroid cancer for patients 0-4years (27). 

To help put that into perspective, in the Republic of Ireland the incidence of thyroid cancer is 3.61/100,000 at baseline (28).

Ionizing radiation imparts a small but real risk of malignancy at the population level. This impact is greater on paediatric patients (29). 

It takes time and a greater degree of patient cooperation to obtain plain films.  As explored above, plain films can have lower sensitivity than CT so require a reliable history and physical examination to back them up as a diagnostic tool. CT has a superior ability to detect critical paediatric cervical spine injury in higher risk trauma patients because it provides more anatomical detail (30, 31). 

Indications for CT imaging (1, 13, 18, 20):

  • peripheral focal neurological signs or symptoms including paraesthesia in upper/lower limb(s)
  • patient is intubated/respiratory failure (severe TBI or C3/4/5 injury damaging phrenic nerve)
  • GCS <13 on initial assessment, pointing to TBI
  • head or multi-system trauma undergoing CT
  • signs of substantial head injury (e.g. signs of base of skull fracture)
  • where an urgent diagnosis is required e.g. for theatre
  • plain films are technically difficult or inadequate
  • strong clinical suspicion persists in spine of normal plain films e.g. symptomatic with head first axial loading as mechanism
  • plain films demonstrate a bony injury

The use of MRI will vary between institutions. 

In patients who have neurological signs on examination, MRI should be the primary modality wherever possible (26). It is often used as a follow on investigation from CT in the intubated sick trauma patient who is unconscious and difficult to assess from a neurological perspective clinically. They are now stabilized enough either via Intensive Care or Surgical input to undergo an MRI.

Younger children with isolated neck injury who are difficult to assess and in whom we are concerned due history and physical examination may also be suitable candidates for MRI (32) post normal plain XR instead of going to CT. Bear in mind that many children will require a general anaesthetic to tolerate this imaging modality as it takes longer than CT or XR to perform.  

A 2 year old girl presents with her father after landing awkwardly post a fall down the last two steps of stairs in her home yesterday evening. She has been starting to walk up and down the stairs and is always supervised. Last night, she complained of some pain which responded to the paracetamol syrup given to her by Dad. She slept well but since this morning, she has been holding her neck strangely and prefers to lie down.

You are the senior registrar on duty and one of your colleagues asks for your review. She is lying in a position of comfort on her left side. When you go to examine her she sits up and clings to her father crying and making it clear that she does not want to be examined, saying bye-bye. She has a torticollis to the left and is moving all limbs. Analgesia was given and plain films were obtained. These looked normal to you and the patient was reviewed and looks more comfortable now, although the torticollis persists.

Should we be concerned? Outline your steps in this patient’s management.

Torticollis in the setting of trauma, even in the absence of neurological signs or symptoms is concerning. 

There is an association between torticollis and cervical spine injury, particularly rotatory subluxation of C1 on C2 (Atlanto axial rotatory subluxation or fixation as it is sometimes termed), however it can also be seen in other patterns of cervical spine injury too (34-38). 

Typically, in trauma, the ipsilateral sternocleidomastoid muscle is in spasm. This differs from torticollis from other causes (benign paroxysmal torticollis, cervical lymphadenitis, cervical spine/cord tumours, posterior fossa tumours) where the contralateral sternocleidomastoid is in spasm (37). 

Despite the fact this little girl’s neurological assessment remained normal, it was decided to proceed to MRI under general anaesthesia. This demonstrated atlanto-axial rotatory subluxation. 

This case emphasises the concerning nature of traumatic torticollis, even in the absence of neurological signs or symptoms.

Injuries sustained by mechanism (33):

Hyper-flexionHyper-extensionAxial Load
Flexion teardropHyperextension dislocationBurst fracture (If occurs to C1 the eponym of Jefferson applies)
Bilateral facet dislocationExtension teardrop
Unilateral facet dislocationHangman’s fracture  (C2 Pedicles)
Anterior subluxation
Wedge fracture
Spinous process fracture

Falls from elevation, MVCs, being struck by motor vehicles while walking or riding and blunt blows to head and neck are more likely to result in axial (C2 and above) CSIs. 

Sports related cervical spine injuries are more likely to result in injuries to the sub-axial (below C2) region or SCIWORA. Children involved in diving and motor sports (All-terrain-vehicles and motorcycles) are more likely to sustain sub-axial cervical spine injuries (8).

What percentage of paediatric spinal injuries are located in the cervical region?

A: 12%

B: 40%

C: 50% or more

D: 2%

C: 50% or more

The cervical spine is overrepresented as the region where more than half of all paediatric spinal injuries occur and the main reason for this is the relatively larger head size leading to the fulcrum of flexion being in the cervical column.

Which of the following mechanisms in history are concerning for a cervical spine injury?

A: Motor Vehicle Collision at a speed of above 30kph (18mph)

B: Diving into a pool

C: Fall from greater than body height

D: Transient neurological symptoms

E: All of the above

E: All of the above

Expert consensus on factors which are suspicious for a CSI include: persistent neck pain, child or parent feeds like the child has an abnormal head position, difficulty with neck movement, fall >1m or 6 steps of stairs or fall from greater than body height, hyperextension injury, acceleration-deceleration injury involving the head or clothes-lining (blunt trauma to the head/neck by a stationary object while the patient is in motion), bicycle collision, pedestrian versus bicycle, accidents involving motorized recreational vehicles, horse riding accidents, current or transient neurological symptoms (motor or sensory): weakness, paraesthesia, lightning or burning sensation down the spine or radiating to an extremity, neurological symptoms related to neck movement.

Plain films are not sensitive enough in children to be our first choice in most circumstances where imaging of the cervical spine is deemed necessary.

A: True

B: False

B: False

The sensitivity of two or more radiographic views for detecting cervical spine injury has been reported to be in the region of 85-94%, whereas CT ranges from 81-100%. These figures reflect the unique anatomical challenges inherent in interpreting images in this patient cohort, particularly those under the age of 8 years old. In adults, by comparison, CT sensitivity sits around 97-100%. This makes plain films a higher yield modality in the paediatric population, backed up by CT where plain film findings are abnormal or ambiguous.

1. Luehmann NC, Pastewski JM, Cirino JA, Al-Hadidi A, DeMare AM, Riggs TW, et al. Implementation of a pediatric trauma cervical spine clearance pathway. Pediatr Surg Int. 2020;36(1):93-101.

2. Jones TM, Anderson PA, Noonan KJ. Pediatric cervical spine trauma. J Am Acad Orthop Surg. 2011;19(10):600-11.

3. Adib O, Berthier E, Loisel D, Aube C. Pediatric cervical spine in emergency: radiographic features of normal anatomy, variants and pitfalls. Skeletal Radiol. 2016;45(12):1607-17.

4. Davies J, Cross S, Evanson J. Radiological assessment of paediatric cervical spine injury in blunt trauma: the potential impact of new NICE guidelines on the use of CT. Clin Radiol. 2016;71(9):844-53.

5. Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics and Trauma. 2018;32(5):288-92.

6. Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, et al. Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age. J Neurosurg Pediatr. 2010;5(3):292-6.

7. Polk-Williams A, Carr BG, Blinman TA, Masiakos PT, Wiebe DJ, Nance ML. Cervical spine injury in young children: a National Trauma Data Bank review. J Pediatr Surg. 2008;43(9):1718-21.

8. Leonard JR, Jaffe DM, Kuppermann N, Olsen CS, Leonard JC. Cervical spine injury patterns in children. Pediatrics. 2014;133(5):e1179-88.

9. Patel JC, Tepas JJ, 3rd, Mollitt DL, Pieper P. Pediatric cervical spine injuries: defining the disease. J Pediatr Surg. 2001;36(2):373-6.

10. Egloff AM, Kadom N, Vezina G, Bulas D. Pediatric cervical spine trauma imaging: a practical approach. Pediatr Radiol. 2009;39(5):447-56.

11. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2):E20. 

12. Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286(15):1841–8.

13. Leonard JC, Browne LR, Ahmad FA, Schwartz H, Wallendorf M, Leonard JR, et al. Cervical Spine Injury Risk Factors in Children With Blunt Trauma. Pediatrics. 2019;144(1).

14. Michelle L. Paucis Verbis: Distracting injuries in c-spine injuries California2011 [Available from: https://www.aliem.com/paucis-verbis-distracting-injuries-in-c-spine-injuries/.

15. Slaar A, Fockens MM, Wang J, Maas M, Wilson DJ, Goslings JC, et al. Triage tools for detecting cervical spine injury in pediatric trauma patients. Cochrane Database of Systematic Reviews. 2017(12).

16. Chan M, Al-Buali W, Charyk Stewart T, Singh RN, Kornecki A, Seabrook JA, et al. Cervical spine injuries and collar complications in severely injured paediatric trauma patients. Spinal Cord. 2013;51(5):360-4.

17. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA, Jr., Wales PW, et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the american association for the surgery of trauma. J Trauma. 2009;67(3):543-9; discussion 9-50.

18. Herman MJ, Brown KO, Sponseller PD, Phillips JH, Petrucelli PM, Parikh DJ, et al. Pediatric Cervical Spine Clearance: A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group. J Bone Joint Surg Am. 2019;101(1):e1.

19. Lee SL, Sena M, Greenholz SK, Fledderman M. A multidisciplinary approach to the development of a cervical spine clearance protocol: process, rationale, and initial results. J Pediatr Surg. 2003;38(3):358-62; discussion -62.

20. National Institute for Health and Care Excellence UK. Head injury: assessment and early management, Clinical Guideline 176 2014 [updated September 2019. Available from: https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-pdf-498950893.

21. Council P-hEC. Pre-hospital spinal injury management– PHECC position paper: Pre-Hospital Emergency Care Council (PHECC), Republic of Ireland; 2016 [updated June 2016. Available from: https://www.phecit.ie/Custom/BSIDocumentSelector/Pages/DocumentViewer.aspx?id=oGsVrspmiT0dOhDFFXZvIz0q5GYO7igwzB6buxHEgeDKIJ1qe4KMTbg0PR6g5rsqv0UG7SxVNTJNy77oXQjs2j1HSTJmgAW%252fSZveFhrJdevzBefQ%252b6h%252bH%252fxwJoeP22ouJte%252begki%252bcrlDSFj6a%252b%252bRVIqMv2PmiT2JVsY5T2RjJpHZlKxsjlq4%252foSxAKwZlBC%252fbAutc5W5Mhuoptkdh9A4Q%253d%253d.

22. Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.

23. Maxwell MJ, Jardine AD. Paediatric cervical spine injury but NEXUS negative. Emerg Med J. 2007;24(9):676-.

24. Kadom N, Palasis S, Pruthi S, Biffl WL, Booth TN, Desai NK, et al. ACR Appropriateness Criteria((R)) Suspected Spine Trauma-Child. J Am Coll Radiol. 2019;16(5s):S286-s99.

25. Swischuk LE, John SD, Hendrick EP. Is the open-mouth odontoid view necessary in children under 5 years? Pediatr Radiol. 2000;30(3):186-9.

26. The Royal College of Radiologists UK. Paediatric Trauma Protocols 2014 [updated 2017. Available from: https://www.rcr.ac.uk/publication/paediatric-trauma-protocols.

27. Jimenez RR, Deguzman MA, Shiran S, Karrellas A, Lorenzo RL. CT versus plain radiographs for evaluation of c-spine injury in young children: do benefits outweigh risks? Pediatr Radiol. 2008;38(6):635-44.

28. Lennon P, editor Thyroid cancer in Ireland, a 10 year review of the national cancer registry. 17th European Congress of Endocrinology; 2015; Dublin, Ireland: European Society of Endocrinology.

29. Puchalski AL, Magill C. Imaging Gently. Emerg Med Clin North Am. 2018;36(2):349-68.

30. Brockmeyer DL, Ragel BT, Kestle JR. The pediatric cervical spine instability study. A pilot study assessing the prognostic value of four imaging modalities in clearing the cervical spine for children with severe traumatic injuries. Childs Nerv Syst. 2012;28(5):699-705.

31. Tat ST, Mejia MJ, Freishtat RJ. Imaging, clearance, and controversies in pediatric cervical spine trauma. Pediatr Emerg Care. 2014;30(12):911-5; quiz 6-8.

32. Booth TN. Cervical spine evaluation in pediatric trauma. AJR Am J Roentgenol. 2012;198(5):W417-25.

33. Easter JS, Barkin R, Rosen CL, Ban K. Cervical Spine Injuries in Children, Part I: Mechanism of Injury, Clinical Presentation, and Imaging. Journal of Emergency Medicine. 2011;41(2):142-50.

34.      Schwartz GR, Wright SW, Fein JA, Sugarman J, Pasternack J, Salhanick S. Pediatric cervical spine injury sustained in falls from low heights. Ann Emerg Med. 1997;30(3):249-52.

35.      Brown P, Munigangaiah S, Davidson N, Bruce C, Trivedi J. A review of paediatric cervical spinal trauma. Orthopaedics & Trauma. 2018;32(5):288-92.

36.      Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors associated with cervical spine injury in children after blunt trauma. Annals of emergency medicine. 2011;58(2):145-55.

37.      Copley PC, Tilliridou V, Kirby A, Jones J, Kandasamy J. Management of cervical spine trauma in children. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2019;45(5):777-89.

38.      Klimo P, Jr., Ware ML, Gupta N, Brockmeyer D. Cervical spine trauma in the pediatric patient. Neurosurgery Clinics of North America. 2007;18(4):599-620.

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Seizures Module

Cite this article as:
Peter Tormey. Seizures Module, Don't Forget the Bubbles, 2020. Available at:
AuthorPeter Tormey
DurationUp to 2 hours
Equipment requiredNone

Basics (10 mins)

Main session: (2 x 15 minute) case discussions covering the key points and evidence

Advanced session: (2 x 20 minutes) case discussions covering grey areas, diagnostic dilemmas; advanced management and escalation

Quiz (10 mins)

Infographic sharing (5 mins): 5 take home learning points

We also recommend sharing a copy of your local guideline.

Unprovoked seizures are common in children with around 8% having a seizure by 15 years of age

  • Most seizures are brief, self-limiting and generally cease within 5 minutes
  • Convulsive status epilepticus is the most common paediatric neurological emergency worldwide and the 2nd most common reason for PICU admission in the UK.
  • A seizure is the clinical expression of abnormal, excessive, synchronous discharges of neurons residing primarily in the cerebral cortex

Was the seizure a primary event or secondary to something else?

Seizures can be due to an underlying epilepsy or can be acute symptomatic seizures due to:

  • Hyponatraemia
  • Hypoglycaemia
  • Hypocalcaemia
  • High fever
  • Toxin exposure
  • Intracranial bleeding
  • Meningitis

Was this really a seizure or should I consider other differentials?

Tonic clonic activity and incontinence are not specific for seizures so always consider differential diagnoses.

  • Differential diagnosis of a seizure:
    • Vasovagal syncope
    • Blue breath holding spell
    • Reflex anoxic seizure
    • Arrhythmia
    • Non-epileptic paroxysmal event

Seek out clues in the history:

A sudden fright or minor trauma followed by the child turning pale and seizing is suggestive of a reflex anoxic event secondary to a vagal reflex. Hypoxia can induce a short tonic-clonic event that looks like a generalized tonic-clonic seizure but the child will recover quickly.

A history of a temper tantrum crescendo-ing into the child holding their breath, turning blue and then seizing might make you think of a breath holding attack. Again, this child will recover quickly.

Standing in a hot, stuffy room, feeling lightheaded with some visual changes and echoey hearing sounds vasovagal. Compare this to a child who describes palpitations or is exercising before the event; this child could have had an arrhythmia.

A 7-year-old boy called Simon is brought to the ED by his parents. At approximately 7am they were awoken by noises coming from his room. They ran in and noticed that the left side of his face was jerking and he was drooling and making gurgling sounds. He wasn’t responding to them.

The movements stopped after 2 minutes. He was drowsy for a few minutes after and had difficulty talking and expressing himself for 15-20minutes after. They also noticed there was a slight drooping on one side of his mouth for 15-20 minutes.

He has now fully recovered and is bright and alert in ED with GCS 15/15 and a normal neurological exam.

What are some of the key elements of Simon’s past medical history that you must ascertain?

How would you classify his seizure? 

Are there clues in the history as to what specific seizure disorder he may have?

Would you perform any investigations at this point?

Does he need to be admitted? Does he need treatment? What follow up will you arrange?

Any history of hypoxic injury at birth?

Did he have any delay in meeting his developmental milestones?

How does his school performance compare to that of his peers?

Is there any history of similar events? Or unusual behaviours or word-finding difficulties on waking from sleep?

The key here is to determine if Simon is an otherwise well child or if there are details in his medical history, such as developmental delay, that may make him more prone to developing epilepsy

It is also important to determine if he perhaps has had more subtle seizures in the past that may have been missed

This is an opportunity to look at the International League Against Epilepsy infographic.

Simon has had a focal motor seizure with impaired awareness.

Specific seizure disorder: Simon’s seizure would be most in keeping with a clinical diagnosis of benign childhood epilepsy with centrotemporal spikes (BCETS) also known as benign rolandic epilepsy.

BCETS usually presents in early school age children with normal development. The most common seizure type is a focal motor seizure involving the face. There may or may not be impaired awareness. They can also be associated with facial numbness, hypersalivation, drooling, dysphasia and speech arrest. Motor activity in the upper, but not lower, limbs is common.  They may also progress to a generalized tonic-clonic seizure. Approximately 75% of seizures occur at night or on awakening and, therefore, can be easily missed. Patients may have a post-ictal paresis, often of one side of the face which can be concerning for a cerebrovascular accident. 

A blood glucose should be checked. 

Electrolytes are often checked with a first seizure but their utility decreases with patient age and degree of recovery. 5

As this history is strongly in keeping with a diagnosis of BCETS, an EEG is not strictly necessary to confirm the diagnosis, however, your local guideline for first seizure management should be followed.

There is no indication for neuroimaging at present.

Patients generally do not need to be admitted after a first seizure with no red flags:

  • Seizure related to head injury
  • Developmental delay or regression
  • Headache prior to seizure   
  • Bleeding disorder or on anticoagulant medication
  • Drug or alcohol use
  • Focal neurological signs or incomplete recovery
  • Seizure >5 minutes
  • Social concerns e.g. parental coping mechanisms or concerns over parental ability to recognize and seek medical attention if another seizure were to occur

Patients with an uncomplicated first seizure generally do not need to be commenced on treatment. BCETS in particular generally has a benign course and rarely requires treatment. 

All children who have a first seizure episode should be referred for paediatric follow up. This may be General Paediatric or Paediatric Neurology follow up and local referral pathways should be consulted. 

The International League Against Epilepsy have a useful infographic for managing a first seizure:


For more information on managing a 1st afebrile seizure see: 


Emily is a 4-year-old girl brought to ED with episodes of disturbed sleep for the last 3 weeks. This is her 4th visit to ED. She was previously diagnosed with “night terrors” and reassured. Her mum is concerned because the episodes are now occurring each night, having previously been 1-2 per week.

Her mum has videos of the episodes, which she shows you. The events usually occur shortly after going asleep. In the videos Emily wakes from sleep, looks terrified and stares straight ahead. The episodes go on for 2-3minutes. She usually vomits or retches towards the end of the episode. She goes back to sleep after. She is well during the day.

What could be going on here?

What interesting details in the history might lead you towards a specific diagnosis?

What could help differentiate between epileptic and non-epileptic events in this case?

What is the prognosis for these patients?

These episodes sound unusual and their frequency and severity seems more pronounced that what could be put down to normal variance in sleep pattern and arousal. Emily’s symptoms are not likely to be simple night terrors.

Seizures commonly occur in sleep and as a result can be missed or present subtly or without characteristic features.

There are several features in the history that would suggest Panayiotopoulous Syndrome (PS). 

PS is a focal epilepsy that occurs in children aged 1-14 years with a mean age of 5 years. The seizures are usually nocturnal

It is thought PS accounts for 6% of children with epilepsy.

There is a strong association with vomiting (70-85%) of patients. Visual symptoms are also closely related, given the seizures originate in the occipital lobe. Autonomic features can also be seen: pallor, tachycardia, miosis, coughing and hypersalivation.

They may also have head or eye deviation and focal or generalized clonic activity.

The diagnosis of PS is often delayed due to misdiagnosis with other causes of vomiting and autonomic manifestatons e.g encephalitis, migraine, syncope or gastroenteritis.

PS could easily be clinically misdiagnosed as night terrors. Night terrors are dramatic awakenings that usually happen during the first few hours of sleep. They share several characteristics with PS but there are also some subtle differences highlighted in the table below:

Clinical FeaturePSNight Terrors
Usual duration 5-10min++
Occur during the first few hours of sleep++
Autonomic Symptoms e.g tachycardia, tachypnea, sweating+++
Impaired awareness++
Child looks scared++
Running or walking around during episode++
Thrashing of arms and legs++

Table 1. Clinical characteristics of PS and night terrors

It is not unreasonable to clinically diagnose night terrors if they present with characteristic events, more in keeping with night terrors than PS. However, if there are unusual features, such as vomiting, or exaggerated autonomic symptoms, or in a child who represents, then an alternative diagnosis should be considered. 

An inter-ictal EEG will usually be diagnostic in PS with occipital spikes, which are enhanced in sleep, the characteristic feature. In a child with unusual events occurring in sleep and a normal EEG, a video telemetry EEG may be useful to try and capture and characterise the events and outrule seizures as a possibility.

PS usually has a benign course with spontaneous remission commonly occurring within 2-3 years of onset. 

Seizures are generally infrequent but oxcarbazepine may be required to reduce seizure frequency.

Emma is a 3-year-old girl with a background of refractory epilepsy and developmental delay. Her current medications include levetiracetam, sodium valproate, clobazam and lamotrigine.

She is PEG fed but has been vomiting up her feeds for the last 2 days and mum is unsure if her medications have been staying down.

She normally has up to 20 short seizures per day at home, but this has been increasing in the last 2 days.

You get a pre-alert from the ambulance service: Emma has been having a generalised tonic clonic seizure for 15 minutes. Her mum gave her buccal midazolam at 5 minutes, but it has not had any effect.

The ambulance crew ask you can they repeat the dose of buccal midazolam?

Emma arrives in resus with the seizure ongoing. What is your management plan?

Emma has had two doses of benzodiazepines. What would be your next line agent? Who else should you be calling at this stage?

You decide to suggest 2 papers, the ConSEPT and EcLiPSE papers for your department’s next journal club and to discuss what effect they will have on your department’s practice. One issue you foresee is that a lot of the patients you see are already on maintenance levetiracetam.

Does this preclude children on maintenance levetiracetam from receiving IV levetiracetam in status epilepticus, as is the case with the use of phenytoin in patients who take it as maintenance treatment?

Emma’s seizure terminated with the second line agent and she was admitted under neurology for IV fluids and ongoing management of her seizures until she could tolerate her medications by PEG again. In this case her status epilepticus was likely due to her vomiting up her medications.

Had Emma’s seizure not stopped after the loading dose of phenytoin, what would your next steps be?

There is a risk of respiratory depression with any benzodiazepine. 

A Cochrane review9 in 2018 found that 25/346 (7.2%) patients treated with buccal midazolam experienced respiratory depression. There was no statistically significant difference in risk of respiratory depression between buccal midazolam and other benzodiazepines, administered via various routes. 

The drug information leaflet or Summary of Product Characteristics (SPC) for Buccolam® and Epistatus® recommend that only a single dose be administered at home by a caregiver and that additional doses should only be administered after seeking medical advice and, preferably, under medical supervision.

In this case, it would be reasonable to advise a second dose of buccal midazolam, presuming the paramedics had the necessary equipment and skillset to manage any respiratory depression that may occur. 

Factors that may influence your decision are: the ETA of the ambulance and if the child has a history of respiratory depression with benzodiazepines.

She should be managed as per the APLS guideline (please note this is the Australian APLS guideline and has been updated to include the use of levetiracetam as a second line agent. This has not yet been included in the UK APLS guideline, see discussion below):

At this point you should be informing PICU about the patient and your PEM consultant if you haven’t done so already.

The CONCEPT and ECLIPSE trials were published concurrently in May 2019.

These two studies looked at whether levetiracetam is non-inferior to phenytoin as a second line treatment in the management of convulsive status epilepticus in children.

This question was posed as phenytoin is linked to many adverse events including liver damage, Steven-Johnson syndrome, extravasation and reports of death due to dosing errors. As a result, and because of its biopharmacology, it is a resource-intensive drug to make up in an emergency.

Levetiracetam can be given over 5 minutes (phenytoin takes 20 minutes to infuse), is more compatible with IV fluids, has less drug interactions, and has a lower risk of adverse events.

The infographic below provides a nice summary:

You can find a more detailed summary at: https://dontforgetthebubbles.com/consept-eclipse-status-epilepticus/

It’s important to note that the primary outcomes of the two studies were different:

ConSEPT – The primary outcome was seizure cessation 5 minutes after the drug infusion and where possible the seizure cessation was verified independently via a video recording to reduce observer bias between the two groups.

EcLiPSE – In a key difference to the ConSEPT study the primary outcome was time “from randomisation to cessation of all visible signs of convulsive activity, defined as cessation of all continuous rhythmic clonic activity, as judged by the treating clinician”. As per the inclusion criteria this a very real world pragmatic approach.

The two studies concluded:

ConSEPT – Levetiracetam is not superior to phenytoin as a second line agent for convulsive status epilepticus

EcLiPSE – There is no significant difference between phenytoin and levetiracetam in the second-line treatment of paediatric convulsive status epilepticus for any outcome, including time to seizure cessation

Here is a section of the commentary from the post:

“While there were differences between the study designs, the primary outcome measure of timing being the largest, the fact that both studies found no difference probably means head-to-head there is little difference.

The nature of the statistical analysis means that both groups rightly point out that in their cohorts levetiracetam wasn’t superior in outcomes to phenytoin. A future pooled analysis could still demonstrate a difference, but it seems unlikely that a critical difference will be seen (especially for the safety element).

Given the wealth of evidence on the side effects of phenytoin it is surprising the incident rates were relatively low. Whether in study conditions more care was taken with drawing up and delivering the drug or that previous safety reviews were heterogenous in their inclusion criteria is difficult to know. However, the time to draw up phenytoin, and the background concerns on its potential harm, will lead some to suggest that the switch to levetiracetam is a logical one, regardless of its effectiveness against phenytoin.

The challenge faced by many units is a capacity for PICU beds. Because phenytoin is given over 20 minutes there is time to prepare for airway/anaesthetic intervention if it is unsuccessful in terminating the seizure. The use of levetiracetam may cause some to wonder if they should then try phenytoin either as a stop gap to bed availability or because the time in status now seems ‘shorter’ than normal. These are not statistical issues, these are pragmatic clinical conundrums.

The absence of a clear winner will further fuel this debate meaning it is unlikely in the immediate future we are going to see a change from the ALSG or similar organisations. However, local units may decide, in the clear absence of harm from levetiracetam, that it is a drug they should be adding into their treatment protocols.”

The EcLiPSE trial2 did not report any increase in adverse events in children who were on maintenance leveltiracetam and received a loading dose of IV levetiracetam. The ConSEPT trial excluded all patients who were on maintenance levetiracetam and phenytoin.

The use of phenytoin in status epilepticus in patients who are on maintenance phenytoin is avoided due to its potential cardiovascular side effects. As levetiracetam does not share these side effects and is generally safe and well tolerated it is reasonable to use it in children who are already on maintenance therapy. 

The EcLiPSE trial2 did not report any increase in adverse events in children who were on maintenance leveltiracetam and received a loading dose of IV levetiracetam. The ConSEPT trial excluded all patients who were on maintenance levetiracetam and phenytoin.

The use of phenytoin in status epilepticus in patients who are on maintenance phenytoin is avoided due to its potential cardiovascular side effects. As levetiracetam does not share these side effects and is generally safe and well tolerated it is reasonable to use it in children who are already on maintenance therapy. 

The current APLS guidance in the UK would be to proceed with RSI. As we have discussed above, the Australian APLS guidelines have changed, in view of the results of the ConSEPT and EcLiPSE, to include the use of an additional second line agent prior to proceeding to RSI. As reported in the ConSEPT trial, treatment with one drug and then the other reduced the failure rate by more than 50% at the expense of only an additional 10 minutes. 

For further discussions on advanced seizure management and RSI, the following podcast is recommended:


Caroline is a 13-year old girl who presents to ED with a first seizure. Her parents describe a generalised tonic clonic seizure that lasted 20 minutes.

She is an otherwise well girl who is doing well in school. The only concern in her past medical history is that she has been having frequent syncopal episodes for the last 12 months. She has been seen by her GP for this who reassured her that syncopal events were common on her age group and advised her to drink plenty of fluids and try and avoid triggers.

Her neurological exam is normal.

How would you proceed? 

Are there any investigations you could perform in the department to investigate the syncopal episodes she reports?

Is there any link between syncope or arrhythmogenic events and seizures?

Caroline is admitted for further cardiac investigations. She also has an EEG diagnostic for frontal lobe epilepsy which is linkced to ion channel abnormalities.

A blood glucose should be checked. If she has returned to her baseline and there were no red flags with regard to the seizure it would be reasonable to arrange outpatient follow up as per departmental protocol and advise her parents what to do if she should have further seizures.

An ECG and a lying-standing blood pressure should be performed.

Caroline has an ECG performed which has features consistent with Type 1 Brugada syndrome.

Seizures may be triggered by cerebral hypoperfusion due to an arrhythmic event. They can often be treated as a primary seizure and the underlying cardiac abnormality may be missed. Long QT syndrome in particular can present with seizures and almost half of affected patients are initially misdiagnosed and treated for epilepsy before the correct diagnosis is made.

Seizures can also be seen as a primary neurological abnormality, related to the cardiac abnormality. Brugada Syndrome is an autosomal dominant condition characterized by ECG alterations and a predisposition to tachyarrhythmias and sudden death. It is caused by a mutation in the genes SCNA5 and SCN1A. SCN5A codes for the alpha subunit of the voltage-gated sodium channel. As the condition is a channelopathy it can also be associated with epileptic seizures with the channelopathy affecting neuronal pathways. 

Caroline has a ECG which is consistent with features of Type 1 Brugada Syndrome.

There is coved ST segment elevation in V1 and V2 with a negative T wave. This is the only ECG abnormality that is potentially diagnostic and is often referred to as Brugada sign.

For an approach to the paediatric ECG have a look at the following DFTB post:


For further reading on the specific ECG findings in Brugada Syndrome, please see:


Which symptom is more commonly seen with Panayiotopoulos syndrome than night terrors?

A: Staring

B: Terrified expression

C: Vomiting

D: Thrashing of arms and legs

E: Tachypnoea

70-85% of seizures in PS are associated with vomiting. Vomiting is not usually described in night terrors. The diagnosis of night terrors should be carefully applied to children having events disturbing their sleep that have a strong
association with vomiting.

Which of the following are side effects of phenytoin but not levetiracetam?

A: Mood disturbance

B: Cardiovascular toxicity 

C: Purple glove syndrome

D: Gingival hypertrophy

E: Stevens Johnson syndrome

The correct answers as B, C, & D

Although levetiracetam and phenytoin have several common side effects, cardiovascular toxicity, purple glove syndrome and gingival hypertrophy are more specific to phenytoin and are not generally seen with levetiracetam. Mood
disturbance is one of the most common side effects of levetiracetam. Stevens Johnson syndrome is also reported with levetiracetam.

Which of the following ECG findings are seen in Brugada syndrome:

A: Coved ST segment elevation in V1-3, >2mm

B: Prolonged PR interval

C: Negative T wave

D: Saddleback ST elevation, >2mm

E: LVH voltage criteria

The correct answers are A, C, & D

  • Brugada Type 1 has coved ST segment elevation in V1-3, >2mm, followed by a negative T wave. This is often referred to as Brugada sign.
  • Brugada Type 2 has >2mm of saddleback-shaped ST elevation
  • Brugada Type 3 can have the morphology of type 1 or 2 but with <2mm ST segment
  • elevation
  • Prolonged PR interval and LVH voltage criteria are not characteristic features of Brugada syndrome

1. Clinical Practice Guidelines : Afebrile seizures [Internet]. [cited 2020 Apr 20]. Available from: https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_seizures/

2. Lyttle MD, Rainford NEA, Gamble C, Messahel S, Humphreys A, Hickey H, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. Lancet. 2019 May 25;393(10186):2125–34

3. https://www.uptodate.com/contents/seizures-and-epilepsy-in-children-classification-etiology-and-clinical-features?search=seizures%20in%20children&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1

4. https://www.ilae.org/education/infographics

5. https://dontforgetthebubbles.com/first-afebrile-seizure/

6. Michael M, Tsatsou K, Ferrie CD. Panayiotopoulos syndrome: An important childhood autonomic epilepsy to be differentiated from occipital epilepsy and acute non-epileptic disorders. Vol. 32, Brain and Development. Elsevier; 2010. p. 4–9.

7. Ferrie CD, Grünewald RA. Panayiotopoulos syndrome: A common and benign childhood epilepsy. Vol. 357, Lancet. Elsevier Limited; 2001. p. 821–3.

8. Weir E, Gibbs J, Appleton R. Panayiotopoulos syndrome and benign partial epilepsy with centro-temporal spikes: A comparative incidence study. 2018 [cited 2020 May 4]; Available from https://doi.org/10.1016/j.seizure.2018.03.002

9. Mctague A, Martland T, Appleton R. Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Vol. 2018, Cochrane Database of Systematic Reviews. John Wiley and Sons Ltd; 2018.

10. Dalziel SR, Borland ML, Furyk J, Bonisch M, Neutze J, Donath S, et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet. 2019 May 25;393(10186):2135–45.

11. Sandorfi G, Clemens B, Csanadi Z. Electrical storm in the brain and in the heart: Epilepsy and Brugada syndrome. Mayo Clin Proc. 2013 Oct 1;88(10):1167–73.

12. Camacho Velásquez JL, Rivero Sanz E, Velazquez Benito A, Mauri Llerda JA. Epilepsy and Brugada syndrome. Neurol (English Ed. 2017 Jan 1;32(1):58–60.

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The 9th Bubble Wrap

Cite this article as:
Grace Leo. The 9th Bubble Wrap, Don't Forget the Bubbles, 2017. Available at:

With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Status epilepticus

Cite this article as:
Chris Partyka. Status epilepticus, Don't Forget the Bubbles, 2013. Available at:

The batphone rings at 5am. You are given a 5 minute ‘heads up’ by paramedics regarding a 3 year old child they are rushing to you with lights & sirens. She has a history of seizure disorder and has been actively seizing for 45 minutes….