HPI: This is a fully vaccinated 18 month female here after seizure activity at home. Mom states she has had three episodes of generalized tonic-clonic activity in the last 12 hours. After her first episode, mom states her temperature was 103.4F and has improved with anti-pyretics but returns and she has had two additional episodes of tonic-clonic movement. Both upper and lower extremities are involved equally and the episode lasts for 60-90 seconds with spontaneous resolution. She has been sleepy afterwards and then acts more normal but is fussier than usual if the fever doesn’t come down. Her last episode was 1 hour ago. She has had no recent trauma, no focal abnormalities, and has otherwise been acting normal until today. She last received acetaminophen 2 hours ago.
T 99F P 130 RR 25 O2 100%
Gen: Is sitting in mom’s lap watching her iphone. NAD, though she is fussy when you examine her ears, she is appropriately consolable by mom afterwards
HEENT: Bilateral TMs normal without erythema or bulge, oropharynx is normal without lesions or erythema, tonsils are normal in appearance without exudate, copious mucoid drainage from nose
Neck: Moving in all directions
CV: S1S2, RRR, no murmurs, gallops, or rubs
Lung: Transmitted upper airway sounds but no wheezes or rales, no focal lung findings
Abdomen: soft, non-tender, non-distended, no HSM, normal bowel sounds
Musculoskeletal: No focal tenderness in extremities
Lymph: mild cervical lymphadenopathy
Neurologic: Appropriately consolable, acting at baseline per mom now, walking normal, moves all extremities appropriately with normal muscle tone, no altered mental status, smiles at you before you attempt to exam
This is a difficult case that we have all likely seen or will definitely see sometime (likely multiple times) in our career. I have intentionally left out the work-up and management of this case because that is what I want to discuss. This is a typically appearing 18 month old with a fever. She is fussy with examination but appropriately consolable by mom like many of our children with viral infections. The difference here is she has had what appears to be complex febrile seizures (three seizures within 24 hours) but is now back at baseline and didn’t appear to have a prolonged post-ictal period. She is fully vaccinated but this is still a presentation that should concern all of us.
So what do you do? We are emergency medicine physicians and we are trained to worry about bad things. The biggest thing on all of our minds should be: “do I need to worry about meningitis in this girl (or other pathology but we are focusing on meningitis for this discussion)?” Unfortunately, there are no consensus guidelines to make our job easy with this one.
Let’s cover the low-hanging fruit first. If this child was still post-ictal, not acting herself per mom, required intubation, required multiple AEDs to stop seizure (i.e. febrile status epilepticus), or had abnormalities on her exam now, she’d get a full septic work-up, antibiotics, and admission along with possible imaging. This case isn’t that easy though.
Febrile seizures affect 2-5% of children aged 6 months – 6 years. 25-30% of these febrile seizures may be classified as a complex febrile seizure. There is also considerable variation within what classifies a child as having had a complex febrile seizure. The child who had two very brief simple appearing febrile seizures within the same 24hr time period is different than the child with prolonged seizure who has failed to return to baseline. Often times, clinical judgment and personal experience comes into play with these variable presentations since there are no consensus guidelines for management.
Despite this variable presentation, our job is to think about bad things. The bad thing we are concerned about with this child is acute bacterial meningitis. There is decreasing prevalence of bacterial meningitis but it hasn’t been eliminated. There are small studies looking at this exact question and most say the same thing, “routine CSF testing is likely not necessary in an otherwise well appearing child without any abnormalities back at baseline but absolutely necessary if additional findings on exam, incomplete antibiotic administration, or unvaccinated.” Najaf-Zadeh et al performed a systematic review and meta-analysis in 2013 found the pooled prevalence of ABM in children with complex febrile seizures to be 0.6% (95% CI 0.2-1.4) but this was derived from only two studies. The overall prevalence of bacterial meningitis in children who had a seizure and fever was frighteningly 2.6% (95% CI 0.9-5.1).
Studies evaluating for acute bacterial meningitis with complex febrile seizure
Green et al 1993
111 children with ABM and seizure
103 comatose or obtunded at presentation
Remaining 8 had abnormal neuro exam or nuchal rigidity
Kimia et al 2010
3 with ABM
Two children with ABM had AMS at presentation
One had contaminated CSF Cx but grew strep in blood
Teach and Geil 1999
11% with complex febrile seizures
None had ABM
Setz et al 2009
6 with ABM
1 with HSV encephalitis (0.3%)
All had AMS on presentation
Casasoprana et al 2013
3 ABM but all with complex febrile seizure
Incidence of ABM 1.9%
Additional clinical symptoms strongly associated with ABM
Fletcher and Sharieff 2013
1 with ABM (0.5%)
None of the 43 children with two brief febrile seizures had ABM
Hardasmalani and Saber 2012
1 with ABM
That patient had febrile status epilepticus
So I ask you again, would you perform a lumbar puncture in this child?
My personal opinion (and I highly recommend and expect deviation from this):
I do not believe I would perform a lumbar puncture in this child but I wouldn’t discharge her home despite appearing well. She is normal appearing on examination now and despite the studies being small and underpowered to really answer the question, most are consistent that children with complex febrile seizure who ultimately have ABM have additional clinical findings (large caveat for this patient is that she is fully vaccinated). Obviously I would not start antibiotics on this patient but I am completely uncomfortable with the thought of discharging her home with complex febrile seizures nor am I a fan of performing a lumbar puncture and discharging home if the cell count is reassuring (culture is my gold standard and I’m sticking to it). If I had hesitated for one second and felt this child just wasn’t acting right to me or if the mom was insistent that she wasn’t right to her, I’d err on the side of lumbar puncture and treatment.
Interestingly, a survey of 353 pediatric emergency medicine physicians and fellows in 10 US hospitals showed only 34% would perform a lumbar puncture in a child with complex febrile seizure. That is significantly lower than expected.
By Jeremiah Smith, MD
Casasoprana A, Hachon Le Camus C, Claudet I, et al. Value of Lumbar Puncture after a First Febrile Seizure in Children Aged Less than 18 months. A Retrospective Study of 157 Cases. Arch Pediatr 2013;20:594-600
Fletcher E, Sharieff G. Necessity of Lumbar Puncture in Patients Presenting with New Onset Complex Febrile Seizures. West Journ of Emerg Med 2013;14:206-211
Green S, Rothrock S, Clem K, et al. Can Seizures be the Sole Manifestations of Meningitis in Febrile Children. Pediatrics 1993;92:527-534
Hardasmalani M, Saber M. Yield of Diagnostic Studies in Children Presenting with Complex Febrile Seizures. Pediatr Emerg Care 2012;28:789-791
Hofert S, Burke M. Nothing is Simple About a Complex Febrile Seizure: Looking Beyond Fever as a Cause of Seizures in Children. Hosp Pediatr 2014;4:181-187
Kimia A, Ben-Joseph E, Rudloe T, et al. Yield of Lumbar Puncture Among Children Who Present With Their First Complex Febrile Seizure. Pediatrics 2010;126:62-69
Kowalsky R, Jaffe D. Bacterial Meningitis Post-PCV7: Declining Incidence and Treatment. Pediatr Emer Care 2013;29:758-769
Najaf-Zadeh A, Dubos F, Hue V, et al. Risk of Bacterial Meningitis in Young Children with a First Seizure in the Context of Fever: A Systematic Review and Meta-Analysis. PLOSOne 2013;8:e55270
Seltz L, Cohen E, Weinstein M. Risk of Bacterial or Herpes Simplex Virus Meningitis/Encephalitis in Children with Complex Febrile Seizures. Pediatr Emerg Care 2009;25:494-497
Teach S, Geil P. Incidence of Bactermia, Urinary Tract Infections, and Unsuspected Bacterial Meningitis in Children with Febrile Seizures. Pediatr Emerg Care 1999;15:9-12
PEM Fellows Journal Watch Quarterly
Your Up-to-date summaries of relevant pediatric emergency medicine literature from the comfort of your home
Editor-in-Chief – Jeremiah Smith
All Articles are archived @ http://www.cmcedmasters.com/pem-journal-watch.html
“How many papers can you get out of one PECARN study…”
Synposis – This was a planned subanalysis of a prospective, multicenter observational study of children ≤ 18 years of age with blunt torso trauma conducted in 20 EDs in the PECARN. They had clinicians document their suspicion for the presence of intra-abdominal injuries needing acute intervention (defined as death due to abdominal injury, surgical intervention, angiographic embolization, blood transfusion secondary to intra-abdominal hemorrhage, or IV fluids x2 nights in patients with pancreatic or GI injury) as < 1% (low-risk), 1-5%, 6-10%, 11-50%, or >50% prior to knowledge of abdominal CT scanning. Their total population was 11,919 patients. IAI undergoing acute intervention was diagnosed in 203 (2%) of patients. Abdominal CT scans were obtained in 2,302/2,667 (86% 95% CI 85-88%) with clinician suspicion ≥ 1% and in 3,016/9252 (33% 95% CI 32-34%) with clinician suspicion <1%. Sensitivity and specificity of the clinical decision rule for IAI requiring acute intervention was 97% (95% CI 76.9-87.7%) and 42.5% (95% CI 41.6-43.4%) compared to 82.8% (95% CI 76.9-87.7%) and 78.7% (95% CI 77.9-79.4%) for clinician suspicion. 35 (0.4%) of patients with a clinician suspicion of <1% had IAI requiring acute intervention. They concluded that the derived clinical decision rule had a significantly higher sensitivity but a lower specificity than clinician suspicion for IAI undergoing acute intervention. They also concluded that the higher specificity that clinician suspicion had did not translate into clinical practice because clinicians frequently obtained abdominal CTs in patient they considered low-risk.
Mahajan P, Kupperman N, Tunik M, et al. Comparison of Clinical Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-Abdominal Injuries After Blunt Torso Trauma. Acad Emerg Med 2015;22:1034-1041
“Is it necessary for me to drink my own urine? No, but I do because it’s sterile and I like the taste.” Patches O’Houlihan
Synopsis – Contrary to what the great Patches O’Houlihan thinks, urine is not always sterile, especially in 2-12month febrile infants with bronchiolitis according to a recent article in Pediatric Emergency Care. Elkhunovich and Wang performed a prospective cohort study enrolling a convenience sample of febrile infants aged 2-12months with bronchiolitis who presented to the emergency department. They were able to enroll 90 patients who had a fever >38°C and had urinalysis and/or urine cultures ordered. Using the new AAP guidelines for diagnosis of UTI (requires pyuria or nitrites on UA plus >50,000colonies on UCx) they found 4.5% (95% CI 1.2-11%) had a UTI and using just UCx 6.7% (95% CI 2.5-13.9%). Small sample size and a predominance of uncircumsized latino males is a large limitation of this study but it is interesting nonetheless.
Elkhunovich M, and Wang V. Assessing the Utility of Urine Testing in Febrile Infants Aged 2 to 12 Months with Bronchiolitis. Pediatr Emer Care 2015;31:616-620
“CRP later gator ”
Synopsis - This paper evaluated reduction in ED LOS by implementing standard bedside CRP testing in previously healthy, now febrile children, presenting to a large Pediatric ED in the Netherlands. Although sophisticated multivariable linear regression modeling and propensity scoring showed a 12 minute decrease in LOS, significant differences in practice patterns and lack of a proven clinical benefit (morbidity and mortality or ED return visits) make this intriguing, but not clinically relevant at this time in our setting.
Nijman RG, Moll HA, Vergouwe Y, Rijke YB, Oostenbrink R. “C-Reactive Protein Bedside Testing in Febrile Children Lowers Length of Stay at the Emergency Department” Pediatric Emergency Care. 2015;31:633-39
“In other news, hospital admissions for “hypoxia” are soaring this year”
Synopsis – This study enrolled healthy patients, ages 5-15, living at sea level, to determine normal oxygen saturations. The majority of patients were Caucasian, with a large Asian minority, and very few African Americans or Hispanics. No patient had an oxygen saturation less than 97%, suggesting that values of 95 and 96% are suggestive of pathology. That said, there is no data to demonstrate clinical significance of values < 97%. This study has limited applicability as ethnic variation and associated skin coloration may alter values and altitude can change baseline values. Informative for Caucasian pediatric patients who live at sea level. Limited clinical relevance.
Elder JW, Baraff SB, Gaschler WN, Baraff LJ. “Pulse Oxygen Saturation Values in a Healthy School-Aged Population.” Pediatric Emergency Care. 2014;31:645-47
“Maple syrup urine disease makes me think of pancakes….”
Synopsis – This was a review article designed to give emergency room providers an understanding of the history of newborn screening programs and what is commonly screened. It also provided information regarding the clinical setting where suspicion for a metabolic or genetic disorder should be high in a newborn patient and what the future directions are for these screening programs.
Lavin L, Higby N, Abramo T. Newborn Screening: What Does the Emergency Physician Need to Know? Pediatric Emergency Care. 2015;31:661-669
“This just in, people don’t always follow-up. In other news..”
Synopsis – This was a retrospective case-control study to determine if specific demographic and clinical factors are associated with aftercare compliance in a population of publicly insured patients with forearm fractures. They found that 68.2% of patients received timely orthopedic after care, 17.5% received delayed aftercare, and 14.3% had no documented aftercare. Patients that were younger and received orthopedic intervention in the ED were more likely to have timely orthopedic aftercare. Older patients and those who did not require orthopedic intervention in the ED were less likely to have timely orthopedic follow-up. Only 77.3% of patients with severe forearm fractures had timely follow-up. There was no association between gender of patient or race.
Jamal N, Iqbal S, Ryan L. Factors Associated with Orthopedic Aftercare in a Publicly Insured Pediatric Emergency Department Population. Pediatr Emer Care 2015;31:704-707
“Nothing funny about this one”
Synopsis – This was a qualitative research design that used one-on-one interviews to understand general ED providers’ experiences with child abuse and neglect. Consistent with grounded theory, they coded the transcripts and collectively refined and identified themes for analysis. They found that barriers to recognizing child abuse and neglect included: providers’ desire to believe the caregiver, failure to recognize that a child’s presentation could be due to child abuse, challenges innate to working in an ED, and provider biases. Barriers to reporting included: factors associated with the process of reporting, lack of follow-up of reported cases, and negative consequences of reporting such as testifying in court. Facilitators were: real-time case discussion with peers or supervisors and belief that it was better for patient to report in suspicious settings.
Tiyyagura G, Gawel M, Koziel J, et al. Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments. Ann Emerg Med 2015;66:447-454
“J-tips for everyone!”
Synopsis – This was a randomized single-dose clinical trial comparing the efficacy of the J-Tip device to vapocoolant spray for reduction of venipuncture pain in young children. 205 children were enrolled and randomized into one of 3 groups: J-tip, vapocoolant (standard of care at their institution), or NS J-tip with vapocoolant in a ratio of 2:1:1. The encounters were videotaped from start to finish, divided into 3 times (before intervention, after intervention, and during venipuncture), and each video was scored (scorers blinded to intervention) individually based on a pain-scoring protocol. All groups had increased pain from baseline to venipuncture overall and they stated they were unable to control for patient anxiety. There was no change in pain from intervention to needle stick with J-tip (i.e. J-tip numbed the skin) and a significant change in pain from intervention to needle stick with vapocoolant and sham J-tip (i.e. didn’t work as well as J-tip). They concluded that the J-tip worked to decrease pain with no decrease in venipuncture success rates.
Lunoe M, Drendel A, Levas M, et al. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med 2015;66:466-474
“Figuring out who needs to go home in a C-collar is a real pain in the neck…. “
Synopsis – Children’s anatomy makes severe cervical injuries rare but unfortunately leads to diagnostic conundrums when they have persistent midline tenderness with negative imaging. The NEXUS pediatric study found midline tenderness to be the most common abnormality as well (39.2%). This was a single center retrospective study looking at children aged 1-15 years who were discharged home in a rigid cervical spine collar (standard of care at Boston Children’s at the time) after blunt trauma over a 5 year time period. Their primary outcome of interest was clinically significant cervical spine injury and their secondary outcome was continued use of the collar after follow-up. They were able to find 307 subjects who met their inclusion criteria and 289 with follow-up information available. 65.4% had follow-up in a subspecialty spine clinic and 84.6% of those were able to discontinue the hard collar after that visit (average time to first visit was 10 days). 115 patients had repeat imaging at spine clinic (3.2% x-rays, 42.3% flexion-extension views, 2.1% CT, and 13.2% MRI). 10.1% were left in the collar due to persistent tenderness without findings on imaging and 2.1% had findings related to their trauma on imaging but none required surgical intervention. The major limitations of this study is that it is retrospective.
Dorney K, Kimia A, Hannon M, et al. Outcomes of Pediatric Patients with Persistent Midline Cervical Spine Tenderness and Negative Imaging Result After Trauma. J Trauma Acute Care Surg 2015;79:822-827
“If Dr. Sachdev was write we’ll never hear the end of it”
Synopsis – This was a retrospective trauma registry analysis looking at healthy children 0 to 17 years of age who presented to a Level I tertiary care pediatric hospital with blunt trauma. Multivariable regression was used in an attempt to identify independent predictors of pelvic fracture. They included 1,121 patients and 87 (7.8%) had pelvic fracture. Predictors evaluated were: pain/abdnormal examination of pelvis/hip (OR 16.7 95% CI 9.6-29.1), femur deformity (OR 5.9 95% CI 3.1-11.3), hematuria (OR 6.6 95% CI 3.0-14.6), abdominal pain/tenderness (Not independently predictive but statistically significant), GCS ≤ 13 (OR 2.4 95% CI 1.3-4.3), and hemodynamic instability (OR 3.4 95% CI 1.7-6.9). 590 patients had none of these predictors and only 1 (0.2%) had pelvic fracture. 86 of 87 (OR 119.1 95% CI 16.6-833) with pelvic fracture had at least one predictor. They also found that if all children had pelvic radiographs obtained, this rule would stop 53% of radiographs. They concluded that children with blunt trauma without pain/abnormal examination of the pelvis/hip, femur deformity, hematuria, abdominal pain/tenderness, GCS ≤ 13, or hemodynamic instability constitute a low-risk population for pelvic fracture with a risk rate of < 0.5%. They felt that this population did not require routine pelvic imaging.
Haasz M, Simone L, Wales P, et al. Which Pediatric Blunt Trauma Patients Do Not Require Pelvic Imaging? J Trauma Acute Care Surg 2015;79:822-832
Pediatric EM Blog
Pediatric EM Fellows at CMC/Levine Children's Hospital.
Disclaimer: All images are the sole property of CMC Emergency Medicine Residency and cannot be reproduced without written consent. Patient identifiers have been redacted/changed or patient consent has been obtained. Information contained in this blog is the opinion of the authors and application of material contained in this blog is at the discretion of the practitioner to verify for accuracy.