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You are seeing a 15 month old who became angry about a toy being taken away, cried, turned blue in the face, passed out, and then developed tonic-clonic activity for 15 seconds. The entire episode lasted 1-2 minutes. The child is playful, drinking from a bottle of juice, and back to baseline in the ED, with a normal physical exam and vital signs. He has never done this before.
Which of the following test(s) is/are most indicated?
- Bedside glucose
- Electrocardiogram
- Point of care hemoglobin
- Non-contrast CT head
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August 14, 2019 at 10:31 pm
B) 1, 2 and 3
The child is presenting with a classic cyanotic breath-holding spell, most common in children aged 6 months to 6 years, but usually first presenting prior to age 18 months. Children become angry or upset, cry, hold their breath, then become cyanotic and lose tone. Some may have seizure activity. A less common variant, pallid breath-holding spells, present as a child that becomes pale and limp after a surprising or startling event, often without crying. Electrocardiogram in first time breath-holding spell is indicated to rule out long QT syndrome. Improvement in the frequency of breath-holding spells is associated with treatment of any anemia, particularly iron deficiency anemia. Bedside glucose is unlikely to be abnormal in a child back to baseline and drinking juice, but it is always prudent to check bedside glucose in anyone who presented with altered mental status or seizure, particularly in children, who have low glycogen stores. Risks of CT radiation far outweigh a significant finding on CT leading to this presentation.