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Pediatric Medicine: Seizures, Croup & Parents Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine.

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Presentation on theme: "Pediatric Medicine: Seizures, Croup & Parents Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine."— Presentation transcript:

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2 Pediatric Medicine: Seizures, Croup & Parents Mike McEvoy, PhD, NRP, RN, CCRN EMS Coordinator – Saratoga County, NY EMS Editor – Fire Engineering magazine Sr. Staff RN – Adult and Peds CTICUs – Albany Medical Center www.mikemcevoy.com

3 Disclosures None I don’t know how to play golf or ski

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5 Mike McEvoy - Books:

6 www.mikemcevoy.com

7 Outline EMS and children Approach to pediatric patients Parents Croup Seizures Summary Questions

8 How Many Kids? Peds account for 5% EMS calls –Only 10% of pedi patients require ALS

9 Pediatric Patients

10 Special Patients: Infants and Children Under 6 mos. 6 – 12 months 1 –3 years 4 – 5 years School age Teenagers (adolescents)

11 Under 6 months: “Little fear” Distract with –bright lights –noises

12 6 – 12 months: “Stranger Anxiety” Smile ALOT Distract with –bright lights –noises

13 1 – 3 years (Toddlers): “Fear of Separation” Very difficult age Keep with parent Remember: –No abstract thinking

14 4 – 5 years (Preschool): “Magical Thinking” Explain yourself Allay fears

15 School aged: “Good conceptual abilities” Reliable historian Easily separated Abstract thinker

16 Teenagers/Adolescents: “Body Image” Privacy Allay fear

17 Pediatric Patient Often mimic provider Calm, matter of fact approach is best

18 Parents (1 = 2+) Every child has a parent (somewhere) Some have more than one!

19 Regardless of age Youngsters nearly always with adults Older kids still require parental consent

20 Patients/Parents Seek a Medical Professional Who Is: Confident Capable Empathetic Communicative: –What you think is wrong –How you will help –What will happen next

21 Bottom Line: 1=2+

22 Respiratory Emergencies Primary cause in children: Hospital admissions Death in first year of life (excepting congenital abnormalities)

23 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

24 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

25 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)

26 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

27 Croup Pathophysiology Narrowed subglottic trachea (edema and mucus)

28 Croup Pathophysiology Narrowed subglottic trachea (edema and mucus)

29 Croup Pathophysiology Narrowed subglottic trachea (edema and mucus)

30 Concerns/History Sudden onset Rapid progression (< 12 hours) Previous croup history Underlying upper airway abnormality Respiratory comorbidities

31 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 common in epi (60 – 70%) than croup (< 10%)

32 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 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.

33 Croup Treatment Mild cases: humidity,  fever, oral fluids Severe: Steroids and nebulized epi –Calm and avoid agitation –Humidified air or O 2 (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

34 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 extremes of life

35 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

36 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

37 Clinical Features: FS 6 months – 6 years old –Majority 12 – 18 months Usually 1 st day of illness (may be 1 st s/s) Often as temp is  rapidly Simple most common, generalized with primarily clonic activity - typically facial/respiratory muscle involvement

38 Etiology/Pathogenesis Unknown; many theories: ?Fever-induced factors proconvulsant in brain development stage or genetics ?Certain brain ion channels sensitive to temperature ?Hyperthermia induced hyperventilation and alkalosis What causes febrile seizures?

39 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)

40 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 1 st 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

41 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

42 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 1 st time FS

43 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

44 “Fever Phobia” Primary fears –Brain damage –Coma –Seizures –Blindness –Death Other contributors –Technology –Pharmaceuticals

45 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 FUOFWS Not an emergencyImmediate test/dx needed ABX usually not indicatedABX for specific subset

46 Fever Interview Questions How measured? Associated s/s? Response to antipyretics? –Not helpful diff. infectious vs. noninfectious Sweating? Pattern? Exposures (people, animals, travel)?

47 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)

48 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

49 Physical exam: Rash? Presence of meningeal signs in older kids, often absent in infants Hemorrhagic rash

50 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, mottling or pallor

51 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

52 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…

53 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)

54 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

55 Summary 1 = 2+ Croup = viral illness 6 mo-3 yo, onset 12-48 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

56 Thanks for your attention! www.mikemcevoy.com


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