Pediatric Medicine:Seizures, Croup & Parents

Mike McEvoy, PhD, NRP, RN, CCRNEMS Coordinator – Saratoga County, NYEMS Editor – Fire Engineering magazine

Sr. Staff RN – Adult and Peds CTICUs – Albany Medical Center

www.mikemcevoy.com

Disclosures• None

• I don’t know how to play golf or ski

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Outline• EMS and children

• Approach to pediatric patients

• Parents

• Croup

• Seizures

• Summary

• Questions

How Many Kids?• Peds account for 5% EMS calls

– Only 10% of pedi patients require ALS

Pediatric Patients

Special Patients:Infants and Children

• Under 6 mos.• 6 – 12 months• 1 –3 years• 4 – 5 years• School age• Teenagers (adolescents)

Under 6 months:

“Little fear”

• Distract with–bright lights

–noises

6 – 12 months:

“Stranger Anxiety”

• Smile ALOT

• Distract with–bright lights

–noises

1 – 3 years (Toddlers):“Fear of Separation”• Very difficult age• Keep with parent• Remember:

–No abstract thinking

4 – 5 years (Preschool):

“Magical Thinking”

• Explain yourself

• Allay fears

School aged:

“Good conceptual abilities”

• Reliable historian

• Easily separated

• Abstract thinker

Teenagers/Adolescents:

“Body Image”

• Privacy

• Allay fear

Pediatric Patient• Often mimic provider

• Calm, matter of fact approach is best

Parents (1 = 2+)• Every child has a parent (somewhere)

• Some have more than one!

Regardless of age• Youngsters nearly always with adults

• Older kids still require parental consent

Patients/Parents Seek aMedical Professional Who Is:

• Confident• Capable• Empathetic• Communicative:

– What you think is wrong– How you will help– What will happen next

Bottom Line:

1=2+

Respiratory EmergenciesPrimary cause in children:

• Hospital admissions

• Death in first year of life (excepting congenital abnormalities)

Croup (laryngotracheitis)• Viral respiratory illness characterized by

inspiratory stridor, cough, hoarseness– Barking cough in infants & young children– Hoarseness in older children & adults

• Usually mild and self-limited illness– Upper airway obstruction & death can occur

Croup Confounders

Sometimes confused with:• Laryngitis (hoarseness only)• LTB (laryngotracheobronchitis) – extends into

bronchi with resultant lower airway s/s (wheezes, rales, air trapping) increased risk for bacterial superinfection

• Bacterial tracheitis (croup) – thick, purulent exudate with s/s upper airway obstruction

Croup Etiology/Epidemiology• Kids 6 – 36 mo, rare > 6 yo, males 1.4:1

• Peak 10p – 4a

• RF: family hx, recurrent

• Viral – parainfluenza type 1 most common, esp. fall/winter(peak = Oct)

• Can be RSV, measles,or other viruses

• Incidence 6% (< 6 yo)

Croup Presentation• Gradual onset 12 – 48 hours

– Initially runny nose, congestion– Progresses to fever, cough, barking, stridor

• Persists 3 – 7 days, gradually normal

• ASSESSMENT KEY = stridor degree– Stridor at rest = significant upper ao– Others keys: retractions, restlessness– Tachypnea typically = hypoxia LOC = ominous sign

Croup Pathophysiology

• Narrowedsubglottictrachea (edema and mucus)

Croup Pathophysiology

• Narrowedsubglottictrachea (edema and mucus)

Croup Pathophysiology

• Narrowedsubglottictrachea (edema and mucus)

Concerns/History• Sudden onset

• Rapid progression (< 12 hours)

• Previous croup history

• Underlying upper airway abnormality

• Respiratory comorbidities

Croup Differentials• Fever – absence ? spasmodic croup

• Hoarseness/bark – absent in epi, FBOA

• Diff swallowing – present in epi, FBOA

• Drooling – rare in croup (10%), common in abscesses, epiglottitis (80%)

• Throat pain – more commonin epi (60 – 70%) thancroup (< 10%)

Wesley Croup Score (0 – 17)

• LOC: WNL/sleep = 0, altered = 5• Cyanosis: none = 0, agitation = 4, rest = 5• Stridor: none = 0, agitation = 1, rest = 2• Air entry: normal = 0, = 1, marked = 2• Retractions: none = 0, mild = 1, mod = 2,

severe = 3

Score = Mild < 2, Moderate 3 – 7, Severe > 8

Wesley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of croup: a double-blind study. Am J Dis Child 1978; 132:484.

Croup Treatment• Mild cases: humidity, fever, oral fluids

• Severe: Steroids and nebulized epi– Calm and avoid agitation

– Humidified air or O2 (keep sats > 92%)

– Dexamethasone 0.6 mg/kg (max 10 mg)• Best orally (PO 1 mg/mL is foul, IV 4 mg/mL

can be mixed with syrup). If NPO, IV or IM

– Racemic epi 0.05 mL/kg (max 0.5 mL) of 2.25% soln diluted NS to 3 mL total volume

• Repeat q 15 to 20 min

– Usually improved in 30 min, epi lasts 2 hrs

Seizures• 3 – 5% of children have a single febrile

seizure in the first 5 years of life

• 30% have additional febrile seizures

• 3 – 6% develop afebrile seizures/epilepsy

• 3.6% risk of a seizure in an 80 year life

• Highest incidence of seizures (all types) are at extremesof life

Febrile Seizure Criteria• Convulsion associated with temp >100.4

• Child < 6 yo

• No CNS infection/inflammation

• No metabolic abnormality with neuro s/s

• No history of afebrile seizures

Febrile Seizure Categories• Simple (benign) = 90%

– Most common– Duration < 15 min; if repetitive total < 30 min– No focal s/s

• Complex– Duration > 15 min; if repetitive total > 30 min– Focal features or postictal paresis

< 10%

< 5% Most complex kids start with first seizure

Clinical Features: FS• 6 months – 6 years old

– Majority 12 – 18 months

• Usually 1st day of illness(may be 1st s/s)

• Often as temp is rapidly• Simple most common, generalized with

primarily clonic activity - typically facial/respiratory muscle involvement

Etiology/Pathogenesis

Unknown; many theories:

? Fever-induced factors proconvulsant in brain development stage or genetics

? Certain brain ion channels sensitiveto temperature

? Hyperthermia inducedhyperventilation and alkalosis

What causes febrile seizures?

Predisposing Factors:• Infection (no virus/bacteria risk)• Immunizations

– DTP: day of vaccine (5.7 x greater risk)– MMR: 8 – 14 days after (2.83 x greater)– Risk subsequent afebrile seizures or

neurodevelopmental disability unchanged

• ? Iron deficiency• Genetic (10 – 20% familial)

Recurrent Febrile Seizures• Overall recurrence rate 30 – 35%

– Vary with age:• 50 – 65% when < 1 yo at first seizure• < 20% older children

• Most recurrences in 1st year, nearly all within 2 years. Risk Factors:– Young age at onset– Hx febrile seizures in 1° relative– Low degree fever in ED– Brief duration between fever onset & seizure

• Meds do not decrease recurrences

Most significant RF

EMS Concerns• Meningitis/encephalitis are main concerns in

child with fever & seizures• Underlying metabolic disorder presenting as a

seizure in child is rare• Helpful predictor of prolonged seizure is focality• Prognosis is very favorable:

– Febrile seizures may recur– Long term deficit extremely unusual– Only slightly higher risk for epilepsy

Emergency Treatment• Scene safety: meningitis?

• C-A-B’s– Capnography invaluable

• Seizures > 5 min need tx– Check glucose– Short acting benzo

• Treat fever

The longer a seizure continues, less likely it is to stop. Median FSE = 68 min; 76% were 1st time FS

Fever Phobia

• What are some misconceptions about fevers and fever management?

• Prior studies indicated that in some populations, up to 80% of parents thought a fever above 40 C (104 F) caused brain damage. 20% thought an untreated fever would continue to increase

“Fever Phobia”• Primary fears

– Brain damage– Coma– Seizures– Blindness– Death

• Other contributors– Technology– Pharmaceuticals

Fever• What defines a fever?

– Rectal temp > 100.5 °F

• Fever = 1/3 pedi outpatient visits, 1/5 pedi ED visits

• Terms (Important to differentiate):– FUO (Fever Unknown Origin) > 101 x 8d– FWS (Fever Without Source) < 1w

FUO FWS

Not an emergency Immediate test/dx needed

ABX usually not indicated ABX for specific subset

Fever Interview Questions• How measured?

• Associated s/s?

• Response to antipyretics?– Not helpful diff. infectious vs. noninfectious

• Sweating?

• Pattern?

• Exposures (people, animals, travel)?

Fever in the Newborn• Lower fever threshold: > 100.4°F (38°C)

• Neonatal fevers (0-28d) require full workup (guidelines don’t work well)

• Fevers in young infants might (29-90d)

• Risk = SBI (Serious Bacterial Infection)

Fever 3 months – 3 years• > 102.2 °F (39°C) warrants evaluation• Haemophilus influenzae type b (Hib) and PNA

vaccines dramatic in cases• > 101.3 rarely associated with teething• Cause usually easy to find (56%)

– Viral (90% = OM)– Bacterial = UTI (females > males)– PNA cases usually have resp s/s on exam

• Oximetry more useful than RR

Physical exam: Rash?

• Presence of meningealsigns in older kids, oftenabsent in infants

• Hemorrhagic rash

Toxic?Toxicity is a clinical syndrome:

1.Lethargy with poor perfusion (cap refill > 2 seconds)

2.Cyanosis or other signs of respiratory distress AND

3.Cold hands/feet,limb pain, mottlingor pallor

Antipyresis• Many parents aim for “normal”

temperature– Daycare, school, work can drive this

• Antipyresis therapy DOES NOT– Reduce morbidity or mortality from a febrile

illness– Decrease the recurrence of febrile seizures

• Antipyresis DOES– Relieve discomfort– Decrease insensible fluid loss

Arguments against antipyresis• Fever is not an illness• Most fevers are short-lived and benign• Fever may protect the host• Degree of fever ≠ severity of illness fever may obscure diagnostic signs• No evidence that kids with fever are at risk

of adverse outcomes such as brain damage• Adverse effects of antipyretics outweigh

benefits…

FEVER and ILLNESS

• Antipyretics may prolong course of illness:– Adults with rhinovirus shed the virus longer– Children with varicella have delayed time

for lesions to crust (about 1 day)– Children with malaria take longer to clear

parasites (75 vs 59 hours)

Therapeutic intervention• Single or combination therapy

– Acetaminophen – Ibuprofen– Single regimens (of either acetaminophen or

ibuprofen) should be adequate for discomforts due to fever

• Remember therapeutic endpoint!– Most studies have evaluated antipyretic efficacy – Very limited data related to discomfort

Summary• 1 = 2+

• Croup = viral illness 6 mo-3 yo, onset12-48 h with insp. stridor, barking cough

• Degree of stridor = severity• Tx: humidity, fever, fluids (steroids/racemic epi)

• FS: 6 mo-6 yo (most 12-18 mo), first day of illness, 90% simple FS

• Stay calm, reassure

• Consider causes, tx any FS > 5 min

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