Emergency Medical Services-CE25
CASE OF THE MONTH — October 2023
Paramedics are dispatched to a private residence for a seizure in a 7-month-old male patient. His parents are present and state that they called 911 when they witnessed full body jerking movements 7 minutes prior to EMS arrival. The child has never had a seizure before and is reported to be a healthy infant that was born full term without complications. The parents have not noted any changes in activity prior to the onset of the seizure. On EMS arrival the patient is actively seizing.
His initial vital signs are HR 134, RR 10, SPO2 92 on RA%.
This patient is actively seizing with a provider impression of Seizure – Active (SEAC). The provider impression, Seizure – Active (SEAC), should be used in any patient encounter where EMS witnesses the seizure, whether the seizure is treated by EMS or not (e.g. the seizure may stop prior to medication administration but if the seizure was witnessed, the correct provider impression is Seizure – Active). This patient should be managed promptly in accordance TP 1231-P – Seizure.
Immediate goals in managing an actively seizing patient are addressing the airway, breathing, circulation (ABCs) and stopping the seizure. Ensure the patient is in a safe location and assess for spontaneous breathing and a pulse. Evaluate for adequate oxygenation and ventilation and initiate basic and/or advanced airway maneuvers as needed per MCG 1302 – Airway Management and Monitoring. Approximately 10-15% of pediatric seizure patients require positional airway support (e.g. jaw thrust, chin lift, shoulder roll, etc.) during a seizure.
Midazolam should be administered promptly, with dosing per MCG 1309. In most cases where EMS responds to a location outside a healthcare facility, no IV will be in place. In these cases, intramuscular or intranasal administration of midazolam are the preferred routes so that the seizure is treated as soon as possible as IV attempts can delay time to treatment.
The patient is noted to be hypoxic with a decreased respiratory rate on initial assessment. Bag-mask-ventilation with supplemental oxygen is performed while optimizing airway positioning. The patient is RED, 8kg on the length-based resuscitation tape. Midazolam (5mg/mL) 0.2mg/kg IM/IN is administered per MCG 1309. The seizure stops. Paramedics initiate cardiac monitoring and establish vascular access. The patient’s temperature is normal. Blood glucose is 99 mg/dL.
Immediate interventions have been accomplished and the seizure has stopped. EMS on scene should complete a patient assessment, in particular looking for signs of trauma in patients presenting with seizure. Seizure can be a presenting symptom for head trauma/intracranial hemorrhage. In addition, EMS should evaluate perfusion (capillary refill, skin color, etc.) as well as a neurologic assessment.
In assessing the neurological status, EMS should first determine if the patient is still seizing. Some subtle signs of seizure include eye deviation, staring, “lip smacking”, unliteral arm or leg movement, or a rapid increase in heart rate. In infants, seizures are more likely to present with these subtle signs. Most patients will have a short post-ictal period prior to return to their baseline mental status.
Pediatric abusive head trauma is one underlying cause that should be considered in a pediatric patient with seizure, though the absolute diagnosis is not likely to be made in the field. A thorough assessment to include looking for signs of trauma is important; any concerns should be communicated to the receiving hospital staff.
The patient is well perfused but remains altered. No subtle signs of seizure are noted. On physical examination, no head trauma is noted. Small bruises are noted on the infant’s chest and back which the parents attribute to a recent fall from the bed while diaper changing. There are no other notable findings on physical examination.
As EMS is preparing for transport, the patient’s heart rate increases and tonic-clonic activity resumes. Paramedics treat the seizure with Midazolam (5mg/mL) 0.1mg/kg IV, since an IV has already been established. The seizure stops shortly after midazolam administration.
This patient should be transported to the most accessible pediatric medical center (PMC) for status epilepticus if ground transport is ≤ 30 minutes per Ref. No. 510 – Pediatric Patient Destination. Status epilepticus is defined as persistent seizure activity for ≥ 5 minutes OR recurrent seizure activity without recovery between seizures1,2. Patients who continue to seize after administration of midazolam would meet the criteria of persistent seizure activity for ≥ 5 min and should be transported to a PMC. In addition, patients that have recurrent seizure activity without returning to baseline mental status between seizures also meet the diagnostic criteria for status epilepticus and should be transported to a PMC for status epilepticus as well
Pediatric abusive head trauma (PAHT) most often results from shaking or blunt impact and can occur in both infants and young children3. PAHT is often termed “shaken baby syndrome”; however, the Centers for Disease Control and Prevention and the American Academy of Pediatrics recommend using the term “abusive head trauma” because it is more inclusive of various mechanisms that can result in head injury to the child and may have legal significance.
PAHT is injury to the intracranial contents or skull of an infant or child less that 5 years old, with the majority of patients being less than a year old. It is often difficult to diagnose since signs of child maltreatment may be subtle and not externally visible. PAHT typically causes cerebral edema, retinal hemorrhage, and subdural hematoma, all of which may not be visible on a field assessment.
Signs of abuse that may be identified in the field include:
- Bruising anywhere on an infant younger than 4 months old
- Bruising on the ears, neck, or torso, especially in children less than four years old
- Bulging fontanelle
- Long bone and rib fractures
Caregivers rarely admit to deliberate abuse of infants and children, usually being evasive and inventing “accidents”, such as falling down stairs/out of a crib/bed, or trauma from other children3.
When PAHT is suspected, a detailed evaluation will occur in the hospital including a thorough history, physical examination, laboratory studies, radiologic imaging and consultation with child abuse specialists as well as reporting to the Department of Children and Family Services (DCFS).
EMS personnel are mandated reporters of child abuse and neglect when suspected per Ref. No. 822 – Suspected Child Abuse/Neglect Reporting Guidelines.
EMS transports the patient to the most accessible PMC. On emergency department evaluation, a subdural hematoma and intraparenchymal hemorrhage are noted on CT scan of the head. DCFS is notified and an investigation follows. Further inpatient evaluation identifies multiple rib fractures of various age consistent with abuse. The patient is managed acutely in the pediatric intensive care unit (PICU).
- The provider impression, Seizure Active (SEAC) should be used for any seizure witnessed by EMS, whether treated or not.
- Status epilepticus is defined as a persistent seizure lasting ≥ 5 minutes OR recurrent seizure activity without recovery between seizures.
- Pediatric patients with status epilepticus should be transported to the most accessible PMC within 30 minutes.
- Consider trauma/abuse for pediatric patients presenting with seizure.
- PAHT results from shaking and/or blunt impact in infants and young children.
- Wylie T, Divyajot SS, Murr N. Status Epilepticus. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK430686/, accessed 9/15/23.
- Brophy GM, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012; 17(1):3-23. https://pubmed.ncbi.nlm.nih.gov/22528274/
- Joyce T, Gossman W, Huecker MR. Pediatric Abusive Head Trauma. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK499836/, accessed 9/15/23.
Authors: Denise Whitfield, MD, MBA