Case of the Month
June 2007

11-month-old male – first time seizure

Dispatch
"Aid 22, 11-month-old female – first time seizure”

En route your crew discusses the following considerations:

• Reasons for seizure in children
• Use of the pediatric assessment triangle
• Pediatric vital signs chart location in aid kit

While en route the dispatcher advises that the patient is no longer seizing.

Scene Size-up
You arrive at a well-kept home in an upper-class neighborhood. The patient’s father, a 29-year-old male, meets you at the front door with the baby in his arms. You ask him to carry the child into the living room where the light is better and there is plenty of room to work. He places the child on the sofa and as soon as you are at the child’s side the father backs away several feet.

Initial Assessment
The child is wrapped in a blanket and appears to be very tired. Her eyes are closed and she seems to have some difficulty breathing. With the child’s appearance and work of breathing you use the pediatric assessment triangle and decide she is SICK; you request ALS. Her skin appears somewhat pale, almost ashen. The child has a brachial pulse rate of 160/min with a respiratory rate of 60/min. Your pediatric vital signs chart indicates that these are both on the very high end of normal. Besides a rapid breathing rate, her breathing seems to be labored. She feels warm, but not febrile.

Initial Treatment
Your partner places an oxygen mask on the child’s face and starts the rate at 10 LPM. The child hardly reacts to the placement of the mask. This lack of reaction concerns you. As you lift the little girl’s shirt you notice some redness on both sides of the chest and a small deformity and darker discoloration just below the left nipple. You decide to initiate transport immediately. During the exam the patient’s father has maintained his distance but has asked several times, “Is she okay?” and “Is she going to be alright?” This is a “scoop and run” call.

Event and Recent History
During transport to meet the responding ALS unit, you ask the father to explain the events that led to the seizure. He states the child was crying but he did not know why. Then he says sadly “I’m sorry.”  He does not elaborate further about today’s events, but states the girl has no significant medical history and takes no medications. She has never had a seizure before.

Further Evaluation and Treatment
As the transport continues the baby’s breathing becomes more rapid and more labored. A tympanic temperature is taken and it is found to be 99.8 degrees F. The child seizes again just before you meet the ALS unit. As the paramedics enter your BLS unit the child vomits forcefully.

The medics assume patient care, initiate an IV line and intubate the patient. To save time the medics bring their kits and continue the transport in your rig. The remainder of the transport is uneventful.

At the hospital the child is found to have two broken ribs on the left side (where you found the deformity and discoloration) and three different sites in the brain where bleeding was occurring. The emergency room staff notifies hospital security and the local police. The father is detained for suspicion of child abuse.

Shaken Baby Syndrome
Shaken baby syndrome is a brain injury that occurs when a baby is violently shaken. Because babies have weak neck muscles and a large, heavy head, the brain will bounce back and forth inside the skull when a child is shaken, resulting in bruising, bleeding and swelling of the brain tissue. These injuries can easily lead to permanent damage or death. Rib fractures are often seen in shaken children as this is where the assailant typically grabs the child when shaking them.

Other signs or symptoms often seen in shaken baby syndrome include:

• Lack of appetite
• Extreme irritability
• Sleepiness
• Vomiting
• Very pale or cyanosis
• Loss of consciousness
• Respiratory arrest

Depending on your service area, it may be a legal requirement for you to report suspected abuse to children or dependant adults. In cases of physical or sexual abuse the police should be notified immediately. In cases of general neglect, squalid environment, or malnutrition, reporting might be made to your local government’s social services agency. Remember: you may be the only chance an abused child has for getting out of a harmful, if not fatal, environment.

View more on shaken baby syndrome
Kids Health (external link)

View more on the pathophysiology of SBS
Wikipedia (external link)

View more information on child abuse
HelpGuide (external link)