PAEDIATRICS

ResponseBulging fontanelle
Sick child - with some examination features to support this eg; Vital signs
Irritable/inconsolable
Apparent neck stiffness
No clear source of fever
Seizure but regained consciousness

ResponseHYPOGLYCAEMIA
Febrile illness - CNS infection
Head trauma
Intracranial causes - Infection, structural abnormality, Bleed (NAI/Head injury)
Metabolic - hypoglycaemia, hyponatraemia, Inborn errors of metabolism
Genetic - infantile spasm
Cardiac - Long QT
Toxins
Febrile seizure
Hypoxia
Epilepsy
Infantile spasms

Go through THE MISFITS and start writing!

ResponseBedside - Exclude metabolic, hypoglycaemia, toxin as cause
BSL
ABG/VBG
ECG

Lab
EUC, CMP, FBC - Exclude metabolic and infective causes
LP if no focal neurology or altered mental staus and suspect meningitis
Cultures

Neuroimaging

• MRI if focal neurology to suggest SOL or encephalitis
• CTB if traumatic brain injury

ResponseSupport airway, High flow oxycent to maintain sats >92% (avoid hypoxia or hypercarpnoea)
Cessation of seizure

• 1st line: midazolam IV 0.1-0.15mg/kg (Buccal or IN 0.3mg/kg) x 2 doses
• 2nd line: Levetiracitam 20-40 mg/kg or phenyton 20 mg/kg IV
• 3rd line Prepare for intubation (Thio/prop/ket or midaz)
• Pyridoxine 100m gIV in children under 6 months

Seek and treat causes (Hypoglycaemia, hyponatraemia, infection)

• Correct hypoglycaemia 2 mL/kg 10% destrose

ResponseOSCE = talk to mum

ResponseDiagnostic criteria: Fever and ALL of:

• Generalised tonic clonic seizure
• Duration <15 minutes
• Complete recovery within 1 hour
• Do not recur in the same febrile illness

Other points to consider:
Age 6 months to 6 years
Simple less likely in developmental delay, progressive neurologic conditions, previous Afebrile seizures.
Look for signs of CNS infection

ResponseSeizures in an acute infecoius illness (particularly gastroenteritis) without documented fever
Features consistent with simple febrile seizure

ResponseFever and ANY of:

• Focal seizure at onset or during seizure
• Duration >15 mins
• Incomplete recovery within 1h
• Recurrence in same febrile illness

ResponseNo investigations are indicated in a simple febrile seizure, where the focus of infection can be identified clinically and the child returns to baseline mental state - (Probably should be immunised too)
Investigations for the source of fever, including lumbar puncture, should be guided by the nature of the presentation and age of the child. See fever
There is no role for EEG in simple febrile seizures and a limited role in complex febrile seizures
In a prolonged or focal febrile seizure, consider CNS imaging after consultation with a senior doctor
RCH
Answers basically justify an investigation to look for cause of fever
Easily justified:
Urine in girl <2yo - UTI common in girl <2
BSL - history of illness, poor intake, ? metabolic problems

ResponseNormal obs, examination, tolerating fluid intake.
Source of fever identified and appropriate treatment/advise given
Clear follow up plan
Ability to access healthcare urgently in event of deterioration
Has safe means of getting home
Parental education/understanding of condition and long term implications
Parental plan for first aid in event of recurrence

ResponseEpilepsy risk
No other risk factors ~1% (Similar to general population)
Fhx of neurodevelopmental problems, prolonged/focal, or febrile status increases risk
Recurrence
50% at 1 year old
30% 2 year old