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
Disclosures
• None
• I don’t know how to play golf or ski
Mike McEvoy - Books:
www.mikemcevoy.com
Outline
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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
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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 a
Medical Professional Who Is:
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Confident
Capable
Empathetic
Communicative:
– What you think is wrong
– How you will help
– What will happen next
Bottom Line:
1=2+
Respiratory Emergencies
Primary 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
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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
• Narrowed
subglottic
trachea
(edema and
mucus)
Croup Pathophysiology
• Narrowed
subglottic
trachea
(edema and
mucus)
Croup Pathophysiology
• Narrowed
subglottic
trachea
(edema and
mucus)
Concerns/History
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Sudden onset
Rapid progression (< 12 hours)
Previous croup history
Underlying upper airway abnormality
Respiratory comorbidities
Croup Differentials
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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%)
Wesley Croup Score (0 – 17)
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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 extremes
of life
Febrile Seizure Criteria
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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
< 10%
• Complex
– Duration > 15 min; if repetitive total > 30 min
– Focal features or postictal paresis
< 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
What causes febrile seizures?
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
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:
Most significant RF
• 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
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
The longer a seizure continues,
– Check glucose
less likely it is to stop. Median
– Short acting benzo FSE = 68 min; 76% were 1st
• Treat fever
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 meningeal
signs in older kids, often
absent 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, mottling
or 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
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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, 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
Thanks for your attention!
www.mikemcevoy.com