Febrile Seizure, partial seizure and Lumbar Puncture (LP)

It was about 2:00 in the morning when I was typing my notes on the night shift for a patient that had presented with chest pain.  I was doing the usual workup to rule out a heart attack when I heard the radio go off and the paramedics and EMS say that they were bringing in a 3‑year-old boy with fever who may have had a seizure in the night.  I barely even heard it.  It was kind of almost in my subconscious as I typed away about my patient with chest pain.  In fact looking back I think it was more like my subconscious heard it.  I continued to ponder about my patient wondering if he in fact was having a heart attack or maybe it was anxiety or some other kind of chest pain, costochondritis, another form of chest wall tenderness, pneumonia .  It could have been a whole bunch of explanations for his chest pain and I didn't have his EKG back and was thinking to myself about how I was going to move forward with his management.  


About 20 minutes later and a couple patients later I happened to be coming out of an exam room and the paramedics were there in the entryway with the 3-year-old child on their gurney and two young adults that looked like they must have been the parents and two older adults who looked like they must be grandparents and the child was on the gurney screaming and crying obviously in discomfort.  I looked up barely to even notice the patient as I had two or three other critically ill patients and the paramedics said hey doc, what room should I take her to.  So, I motioned to them to take him over to one of the side rooms and let the family know I'd be in there in a minute and I told the nurse,  to start getting the patient hooked up to monitors, etc.  I thought to myself "oh this is going to be another febrile seizure", not a big deal.  We see these all the time. I entered into my office room to continue to chart on another patient.  There was something about the child's cry or maybe it was the parents' faces  I thought to myself, you know I better go and see this patient, this 3-year-old boy real quick and see what's going on.  I went in there and he looked uncomfortable and he looked "sick" and his parents were definitely scared but the parents are always scared.   I went over to the boy and looked at him to see if he was postictal and he did not look right to me.   I continued to talk to the parents and the nurses were scurrying around to get the orders that I had put in for the patient, getting a temperature, hooking the child up to the heart monitor and getting an IV access, etc., etc.  As I explained to the parents what a febrile seizure is and the nurse says to me "doctor, this kid's temperature is 105".  I said okay, give a Tylenol rectal suppository stat and at this point the mom was starting to cry and I put my hand on her shoulder and explained to her that we're going to take care of her child and just as I was explaining this the nurse yelled out, "hey doctor, pulse rate is 280".  


I stopped mid-sentence with the mother and immediately went to the patient's side to begin further examination and looking at the patient, immediately noticed that the patient was having some kind of a seizure, not a toniclonic seizure where the patient is unconscious and their entire body is shaking all over but this looked like a partial seizure to me, where the patient appeared to be awake.  Both of his legs were stiff and plantar flexed and his right arm was contracted almost like he was having a stroke.  The parents could tell by the look on my face that this was a little bit more serious than I had originally thought and I had the nurses move the patient over to the trauma bay so we could prepare to intubate the child and further manage the child.  


The nurses took the patient to one of the resuscitation rooms and I explained to the parents what was going on and what I planed on doing to treat their child's illness.  Once over in the other room my attending physician finally came in and I was preparing to intubate the child and I was giving medications to stop the seizures. It's always difficult when you have a sick child.  You have to remember the pediatric doses and all the treatments are slightly more complicated because you are dealing with a much smaller patient. Everyone is on their toes when you have an innocent child suffering, it just creates a slightly more intense atmosphere. I let the parents and the grandparents stay in the room the entire time. They stood at the child's side and comforted him while what must have seemed like a ball of confusion whirled around them.  So, we gave the child medication.  We called respiratory down and prepared to intubate the child.  After two rounds of medication I was able to get the child's seizures to break.  I was able to get the child's temperature from 105 down to 101 and ultimately was able to intubate the child and it is no small task to intubate a small child, especially with the parents and grandparents in the room and get the child hooked up to the ventilator and we were able to do a spinal tap and start antibiotics and then get on the phone with a pediatric ICU hospital and have the patient transferred over where they had the facilities (pediatric ICU) to continue the long term treatment for the patient.


I have not yet heard what the pathology was in this case. I think that the child had meningitis or some other infection causing these high temperatures  leading to the seizures. However these seizures where not like the typical febrile seizures, so there may have been additional pathology going on with this child. He was healthy without any problems up until this point and hopefully he will return to his normal healthy state but you can't be sure. I will follow up with this case to see what ultimately happened. Hopefully his parents quick response and our quick medical management prevented any longterm deficits from occurring. We did everything we could in a quick fashion; stopped the seizures by bringing the fever down and giving anti-seizure medications, we performed a spinal tap to diagnose meningitis if in fact he had meningitis, we started broad spectrum antibiotics to cover for infections including meningitis, protected his airway by intubating him and finally we got him to a pediatric hospital where he could receive further care and evaluation.