fits Flashcards
types of fits
generalised means that the child is unaware of their surroundings. Focal means that they are awake and the fit is affecting a part of the body.
management of a fit
depends on whether you have access to any oxygen or drugs.
If the fit continues beyond 4 or 5 minutes, call for help. Measure the time accurately.
First give oxygen straight away. If you have a nasopharyngeal airway, it may help to hold the airway open. Oropharyngeal, or Guedel, airways are usually impossible to insert because the jaw is clamped shut during a fit
The next step is to give drugs to stop the fit. Most hospitals in the UK follow the APLS or EPLS guidelines. It is better to spend a few moments getting intravenous access and giving a drug slowly and safely, if you are used to doing this. If not, the buccal route is useful for parents.
Check a blood sugar on the blood that you obtain when getting intravenous access, or if you do not have any blood at this early stage, you need a heel prick blood glucose.
management after a fit
do ADCDENTT to look for complications and cause of fits
Remember Dextrose in D
B - if fit was prolonged or had to use drugs, breathing may be affected
Circualtion - may have lost fluids to sweating during the fit, be dehydrated or have sepsis. HR will be high at first - keep an eye on it.
disability or neurological examination - an AVPU score will usually show that the child is on P or U at this stage. T Try to do a full Glasgow Coma Score so that you can monitor progress as the child hopefully wakes up. Check the pupils. These may be small or large, or deviated during a fit, but should not be asymmetrical. Once the child is wake you need to do a more full neurological examination to see if there are signs which are important for identifying a cause. This child demonstrates something called clonus, which happens with brain damage. He has cerebral palsy. Remember that D also stands for Dextrose. A blood sugar must be checked if a child is not alert. So in this situation it is important to check their blood glucose, because hypoglycaemia is an easily correctable cause of fits, and in itself, causes brain damage. ENT examination is useful if this is a febrile convulsion. Temperature is usually above average immediately following a fit, due to the muscular activity. However it is not usually over 38 degrees centigrade. In all cases it is useful to give paracetamol or ibuprofen, both to cool the patient, and because it will help with any headache
red flags
fits in children only a few months old. They may be subtle and present as lip smacking or eye deviation
aspiration - reduced 02 sats, respiratory distress or high respiratory rate. usually vomit seen. recovery position helps to prevent this.
hypoglycaemia - can cause brain damage. check glucose during a fit and in the post-ictal stage unless child is qute awake. hypoglycaemia may be due to ill child before fit (e.g. sepsis or not eating), may be a diabetic on insulin, congenital metabolic disorders or alcohol overdose. Can cause jitteriness or fits in small babies.
status epilepticus
causes of convulsions
The commonest cause of fits in children is a ‘febrile convulsion’.
However other causes of fits must be excluded including - - metabolic causes (such as low glucose, sodium, calcium)
- head injury,
- CNS infection
- Epilepsy
- Encephalitis/meningitis
- Reflex anoxic seizure
describe a febrile convulsion
Usually in toddlers
Usually a family history
Usually stop before 5 minutes
Usually generalised tonic-clonic
history of fits
The Fit Itself
What were they doing when the fit started?
How did the fit start?
Was there loss of consciousness?
Were bladder/bowels opened?
What the movements were like, and in which parts of the body?
Was there eye rolling?
Was there tongue biting?
What was the tone?
What was the colour?
How long did it last?
How did it stop? (was it self resolving?)
Were they sleepy afterwards (how long was this post-ictal phase?)
Was there headache afterwards?
Was there any injury sustained?
After a description of the fit you need to ask about what happened before the fit:
Was there a fever?
Has the child been unwell recently?
What is the past medical history?
What is the birth history?
Has the child been developing normally?
Did the child complain of anything prior to the fit?
Were they exercising? (cardiac syncope may come suddenly at rest, or during exercise)
Fits with fever
Do not assume a ‘febrile convulsion’. Remember that CNS infections (meningitis and encephalitis) also cause fever and fits. Check for signs of meningism / bulging fontanelle. Check for personality or behaviour change.
Even in the case of a febrile convulsion, remember to make sure that you find the cause of the fever and assess the child for serious bacterial infection. This includes a thorough examination and urine check at the least. Blood tests may be required.
Children who have epilepsy may also have their fit threshold lowered by fevers. We do not call these febrile convulsions.
examination of fits
Generalised fits
- Tonic-clonic fits are the most common and involve
whole body jerks (the tonic phase is the initial stiffening,
the clonic phase is the jerking)
- The eyes are usually rolled upwards, the jaw is
clenched and the child is unresponsive
Focal fits
- The child is awake and the fit only affects a part of the
body
- Neuroimaging may be required for a first focal fit
Sometimes a generalised fit starts as a focal fit.
During fits
- Remain calm and place the child in the recovery
position
- Check the time that the fit started
- Give facial oxygen
- Check the blood sugar and treat if low
- If the fit continues for 5 minutes it will need
benzodiazepine drug treatment
- If you have IV access give lorazepam IV according to
guidelines
- If IV access is unobtainable give buccal midazolam or
rectal diazepam according to guidelines
- Watch out for respiratory depression after using these benzodiazepines
Don’t forget to check the blood glucose
