Marker to patient’s head Cardiac Pericardial effusion a For Low-frequency Anechoic fluid in Pericardiocentesis probe the pericardial space between Subxiphoid, the pericardium marker to and patient’s right myocardium, Parasternal long, tracks anterior to marker to descending aorta patient’s left hip in parasternal long view details, see Chapter 131 Ultrasound SUMMARY Respiratory distress is one of the most common chief complaints of children seeking medical care History and physical examination provides important clues that allow rapid localization of the site of impairment The underlying cause must be identified and may be within the respiratory system or organ systems that control or impact respiration Any disorder that causes respiratory distress may be life threatening Airway and ventilatory problems not only must be recognized but also must be anticipated and addressed aggressively The underlying cause must also be treated Patients must be monitored continuously and reassessed frequently Airway, breathing, and circulation must be established and maintained Diagnostic evaluation of body fluids, radiologic studies, direct visualization, and specialized tests of organ function must be performed prudently so that respiratory status is not further compromised Suggested Readings and Key References Cherry JD Clinical practice Croup N Engl J Med 2008;358(4):384–391 de Caen AR, Berg MD, Chameides L, et al Part 12: Pediatric advanced life support: 2015 American Heart Association Guidelines Update for cardiopulmonary resuscitation and emergency cardiovascular care Circulation 2015;132(18 Suppl 2):S526–S542 Gadomski AM, Permutt T, Stanton B Correcting respiratory rate for the presence of fever J Clin Epidemiol 1994;47(9):1043–1049 Hammer J Acute respiratory failure in children Paediatr Respir Rev 2013;14(2):64–69 King C, Henretig FM, King BR, et al., eds Textbook of pediatric emergency procedures 2nd ed Baltimore, MD: Williams & Wilkins; 2007:85–251, 383– 409, 823–901 Krauss BS, Harakal T, Fleisher GR The spectrum and frequency of illness presenting to a pediatric emergency department Pediatr Emerg Care 1991;7(2);67–71 Louie MC, Bradin S Foreign body ingestion and aspiration Pediatr Rev 2009;30(8):295–301 McIntosh K Community-acquired pneumonia in children N Engl J Med 2002;346(6):429–437 Miller EK, Gebretsadik T, Carroll KN, et al Viral etiologies of infant bronchiolitis, croup and upper respiratory illness during consecutive years Pediatr Infect Dis J 2013;32(9):950–955 O’Dempsey TJ, Laurence BE, McArdle TF, et al The effect of temperature reduction on respiratory rate in febrile illnesses Arch Dis Child 1993;68(4):492–495 Pfleger A, Eber E Management of acute severe upper airway obstruction in children Paediatr Respir Rev 2013;14(2):70–77 Ralston SL, Lieberthal AS, Meissner HC, et al Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis Pediatrics 2014;134(5):e1474–e1502 Shah SN, Bachur RG, Simel DL, et al Does this child have pneumonia?: the rational clinical examination systematic review JAMA 2017;318(5):462–471 Tibballs J, Watson T Symptoms and signs differentiating croup and epiglottitis J Paediatr Child Health 2011;47(3):77–82 CHAPTER 72 ■ SEIZURES AMIR A KIMIA, VINCENT W CHIANG Seizures are the clinical expression of abnormal, excessive, synchronous discharges of neurons residing primarily in the cerebral cortex This paroxysmal activity is intermittent and its duration may last from a few seconds to many hours Seizures represent a neurologic emergency either due to the underlying cause (e.g., bleed, infection) or the potential for neuronal death as a result of a prolonged seizure Approximately 5% of children will have at least one seizure in the first 16 years of life The immature brain, particularly in the neonate and young infant, differs from the adult brain in the basic mechanisms of epileptogenesis and propagation of seizures It is more prone to seizures, but seizures are also more apt to disappear as the child grows Physicians must have a fundamental knowledge of seizure classification (semiology), all aspects of seizure management (including initial stabilization), determination of cause (differential diagnosis), appropriate definitive treatment, and patient disposition BACKGROUND A seizure is defined as a transient, involuntary alteration of consciousness, behavior, motor activity, sensation, and/or autonomic function caused by an excessive rate and hypersynchrony of discharges from a group of cerebral neurons A convulsion is a seizure with prominent alterations of motor activity Epilepsy, or seizure disorder, is a condition of susceptibility to recurrent seizures Seizures may be generalized or partial Generalized seizures reflect involvement of both cerebral hemispheres These may be convulsive or nonconvulsive Consciousness may be impaired and this impairment may be the initial manifestation Motor involvement is bilateral Types of generalized seizures include absence (petit mal), myoclonic, tonic, clonic, atonic, and tonicclonic (grand mal) seizures Partial (focal, local) seizures reflect initial involvement limited to one cerebral hemisphere Partial seizures are further classified on the basis of whether consciousness is impaired When consciousness is not impaired, the seizure is classified as a simple partial seizure Simple partial seizures may have motor, somatosensory/sensory, autonomic, or psychic symptoms When consciousness is impaired, the seizure is classified as a complex partial seizure Both simple and complex partial seizures may evolve into generalized seizures (Jacksonian spread) The spread to deep subcortical regions and evolution to a bilateral tonic- clonic seizure is now called bilateral tonic-clonic seizure (previously referred to as a secondarily generalized seizure), to differentiate it from seizures that are generalized from the onset It is important to recognize that generalized seizures with focal manifestations are also considered focal These manifestations may include lateral eye deviation, head tilt, postictal Todd paresis (or paralysis), or psychomotor seizures (also referred to as temporal lobe seizures) Status epilepticus is a form of prolonged seizure This is defined as seizures lasting more than minutes or repetitive seizure activity without recovery of consciousness in between episodes This is an operational definition used to guide therapy While only 25% of pediatric seizures last longer than minutes, the longer a seizure persists, the more difficult it becomes to control If a child is seen in the ED with a reported/witnessed generalized seizure that has resolved, a 30minute cutoff is used to define status, because 30 minutes is when the risk of permanent neuronal injury increases significantly Status epilepticus is the highest form of seizure emergency A postictal (decreased responsiveness) period usually follows a seizure During this time, the patient may be confused, lethargic, fatigued, or irritable; also, headache, vomiting, and muscle soreness may occur In general, the length of the postictal period is proportional to the length of the seizure For brief seizures, there may be few or no postictal symptoms Transient focal deficits (e.g., Todd paralysis) may occur during the postictal period, but one must first rule out a focal central nervous system (CNS) deficit PATHOPHYSIOLOGY The underlying abnormality in all seizures is the hypersynchrony of neuronal discharges Cerebral manifestations include increased blood flow, increased oxygen and glucose consumption, and increased carbon dioxide and lactic acid production If a patient can maintain appropriate oxygenation and ventilation, the increase in cerebral blood flow is usually sufficient to meet the initial increased metabolic requirements of the brain Brief seizures rarely produce any lasting effects Multiple animal studies and a recent study in humans indicate that 30 minutes of generalized convulsive status epilepticus increases the risk of permanent neuronal injury Systemic alterations may occur with seizures and result from a massive sympathetic discharge, leading to tachycardia, hypertension, and initially stress hyperglycemia Failure of adequate ventilation, especially in patients in whom ... Paediatr Respir Rev 2013;14(2):64–69 King C, Henretig FM, King BR, et al., eds Textbook of pediatric emergency procedures 2nd ed Baltimore, MD: Williams & Wilkins; 2007:85–251, 383– 409, 823–901... 823–901 Krauss BS, Harakal T, Fleisher GR The spectrum and frequency of illness presenting to a pediatric emergency department Pediatr Emerg Care 1991;7(2);67–71 Louie MC, Bradin S Foreign body ingestion... HC, et al Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis Pediatrics 2014;134(5):e1474–e1502 Shah SN, Bachur RG, Simel DL, et al Does this child have pneumonia?: