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You are seeing a 12 year old child that presents with altered mental status, fever, and history of headache and vomiting before the decline in mental status. The patient has a seizure on arrival to the ED, which resolve with lorazepam IV. The CT scan shows evidence of a subdural fluid collection. The lumbar puncture results show a neutrophilic pleocytosis with an elevated protein. Gram stain is negative.
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You are seeing an 8 year old boy brought in by ambulance for a first time unprovoked afebrile seizure. The seizure was generalized tonic-clonic and lasted 3 minutes then self-resolved. The child is now back to baseline. A thorough history and physical exam has revealed no clear etiology for the seizure, and the neurologic exam is normal. The child was well prior to the seizure and has no significant past medical history. Blood glucose in the field was 98. The child is well-appearing and can easily obtain follow-up with his primary physician in a timely fashion.
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A 10 day old presents with shaking of bilateral upper extremities and jitteriness. The patient was a term infant born NSVD with no complications. He is afebrile, HR 140, RR 50, and currently not having any abnormal movements. He has been feeding and urinating normally. His blood glucose is 120. Labs, EKG, head CT, and a CXR are performed – the CXR is shown here.
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You are seeing a 9 year old boy who returned from a camping trip in Colorado 6 days ago. He had some vague complaints of paresthesias, myalgias, and general fatigue the night before. On waking this morning, he had significant bilateral lower extremity weakness and ataxia that rapidly worsened. He is afebrile. On exam, he has no patellar or Achilles deep tendon reflexes.
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You are seeing a 3 year old ex-premature infant who has a ventriculoperitoneal shunt in place. The patient presents with fever to 38.3, cough, and runny nose. There is no headache, vomiting, or altered mental status. The shunt was placed initially while in the NICU, and revised 4 months ago.
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You are seeing a 3 year old child with unrepaired Tetralogy of Fallot who presented with a generalized tonic-clonic seizure, and residual hemiparesis and speech difficulty after waking up from the post-ictal phase.
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EMS is bringing you a 10yo patient that has been actively seizing for 20 minutes. They are unable to obtain IV access.
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EMS has brought in an 8 month old child who had a generalized tonic-clonic seizure at home. The child has a history of 2 prior febrile seizures, starting at age 6 months, and is not on any long-term anticonvulsants. There is no other significant PMH. The child was given IM Ativan 1mg by EMS with resolution after 10 total minutes of seizure. Vital signs are temp 37.9, HR 160, RR 10, BP 72/42, O2 sat 90% room air, weight 7 kg, POC glucose 110. An IV is now in place. What is the MOST appropriate first intervention, assuming all can be instituted within the same amount of time?
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You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air.
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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?
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You are seeing a 1yo child in status epilepticus (first time seizure). The child received 0.2 mg/kg intranasal midazolam in the field, 0.1 mg/kg IV lorazepam in the ED, then 20 mg/kg fosphenytoin, 60 mg/kg levetiracetam, and 40 mg/kg valproate, with no cessation of seizures. The bedside glucose and i-stat Na and Ca are normal. Which vitamin might you try next?
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A 12 year old boy with a history of ADHD on Adderall comes in for acute onset weakness of his bilateral upper arms, particularly on the right side. He had a viral URI 1 week ago with fever, cough, congestion, sore throat, from which he had recovered. For the past week, he did not take the Adderall because he had been sick and “forgot” to resume. On physical exam, his right arm is flaccid and motionless at his side, and he is unable to use it at all. He is able to lift his left arm partly against gravity, but it is weak. He has a low-grade fever of 38, and mild neck stiffness. His mental status is normal.
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A 2 year old child has a flat lesion of the entire left forehead and upper eyelid the color of light red wine that has been present since birth. The family has presented to the ED because they are concerned that the child has right sided weakness.
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A 4 year old with ventriculoperitoneal shunt revision 1 month ago, presents with headache and vomiting and increased sleepiness according to mom. The patient is well appearing and nontoxic, tolerating po’s in the ED, and has a normal funduscopic and neurologic exam. He got acetaminophen 2 hours ago and has no headache currently.
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A 14 month old is brought in with lethargy and obtundation. The patient is breathing spontaneously and has stable vital signs. The parents admit that they were having a party with alcohol and recreational drugs present, and the toddler had been walking around.
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You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED.
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A 19yo man presents with progressively worsening extremity numbness in a glove and stocking distribution and ataxia x 1 month. He has areflexia, weakness, and a wide-based gait on exam. (Click the link to comment and to vote - voting not working through email, sorry!)
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A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a child who has had a self-resolving 5 minute generalized tonic-clonic seizure for the first time. The patient is afebrile, previously healthy, and has a normal non-focal neurologic exam. There is no evidence on your evaluation of another cause for the seizure, such as meningitis or a toxicological cause. There is no associated headache or vomiting. Family history if non-contributory. MRI is unavailable from the ED.
Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 15 month old brought in for simple febrile seizure lasting 2 minutes. The child is back to baseline and well appearing. The vital signs are temperature 40.4 C, HR 175, RR 30, BP 80/40. Exam reveals no source for infection. The child has no vaccinations at all by parent choice.
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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 4 year old child in significant distress due to a headache, which he has had for 2 days. It is bilateral, frontotemporal, not sudden onset, never had before. No associated fever, vomiting, neurologic abnormalities, relevant past medical history. Do you image?
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Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!
You are seeing a 4 year old in status epilepticus. The patient is not on anti-epileptics at home. The patient has received benzodiazepines x 3 and fosphenytoin 20 mg/kg. Glucose and electrolytes are normal. The patient is afebrile.
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PEM Infographics (linked here) has many helpful infographics. One of my all-time favorites is how to use rock-paper-scissors-OK sign to test children's peripheral nerves in the upper extremity / hand exam
Success rates in infant lumbar punctures may be declining as we do fewer and fewer (doing fewer is a good thing, except that we get less experience). One thing that can improve success is early stylet removal. The stylet is kept in when entering the skin in order to avoid the very rare complication of intraspinal epidermoid tumors. However, once the needle is past the epidermis and dermis, such that a plug of skin tissue cannot be cored out by the hollow needle and deposited into the spinal canal, the stylet can be removed. Here are two excellent FOAMed discussions of this practice and the advantages: http://pemcincinnati.com/blog/wwdwwd-early-stylet-removal-lp/ and https://pedemmorsels.com/spinal-needle-stylet/
Mucosal atomizer devices improve administration of intranasal medications. Intranasal fentanyl 1.5 mcg/kg is a great way to give stronger pain medication (eg for fractures) without placing an IV. Intranasal midazolam 0.2 mg/kg (use concentrated 5mg/mL form to keep total volume < 1mL per nostril) can be used to treat active seizures when no IV access is yet obtained, or as an anxiolytic for procedures. Intranasal naloxone at a standard dose of 4 mg is being provided to opiate addicts to use in case of overdose.
A commercial device is available, but currently some lots are being recalled (check here for recalled lots), or you may simply not have one in stock. Here's how to make an improvised atomizer courtesy of Faisal Alghamdi of KFMC Riyadh. Hook up a 3 way stopcock with the lever turned so that all 3 ports are open to 1) a 14 or 16 gauge angiocath, 2) a syringe with the medication you wish to deliver, and 3) oxygen tubing. Hook the other end of the oxygen tubing up to oxygen and turn up to 5-10 L/min. Place the angiocath in the nostril and gently & slowly depress the plunger of the medication. See picture and video below.
Click here to see a video and compare to commercial device here
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