A 12-month-old girl is brought to the emergency department by ambulance for evaluation of a generalized tonic-clonic seizure. About 1 hour ago, the mother witnessed rhythmic jerking of the patient's arms and legs and called 911. By the time the paramedics arrived, the jerking had stopped, lasting a total of 7 minutes. She was born at 32 weeks gestation but has no chronic medical conditions. Her maternal uncle had seizures as a child. Temperature is 40 C (104 F), blood pressure is 100/65 mm Hg, pulse is 150/min, and respirations are 30/min. The patient appears drowsy but is in no distress. The anterior fontanelle is open, soft, and flat. The neck is supple. Cardiopulmonary examination is normal. She is difficult to rouse but withdraws from painful stimuli. Skin examination appears normal. Which of the following is this patient's indication for lumbar puncture?

Question

A 12-month-old girl is brought to the emergency department by ambulance for evaluation of a generalized tonic-clonic seizure.  About 1 hour ago, the mother witnessed rhythmic jerking of the patient's arms and legs and called 911.  By the time the paramedics arrived, the jerking had stopped, lasting a total of 7 minutes.  She was born at 32 weeks gestation but has no chronic medical conditions.  Her maternal uncle had seizures as a child.  Temperature is 40 C (104 F), blood pressure is 100/65 mm Hg, pulse is 150/min, and respirations are 30/min.  The patient appears drowsy but is in no distress.  The anterior fontanelle is open, soft, and flat.  The neck is supple.  Cardiopulmonary examination is normal.  She is difficult to rouse but withdraws from painful stimuli.  Skin examination appears normal.  Which of the following is this patient's indication for lumbar puncture?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff5_5756_8f63_adac9f617941_MD0005_00 Although convulsions in the setting of fever are common in young children and often benign, concerning history and/or physical examination findings may warrant evaluation for meningitis. Simple febrile seizures are generalized, last <15 minutes, and do not recur within 24 hours. Postictal drowsiness typically lasts up to 10 minutes. Febrile seizures are a clinical diagnosis in children age 6 months to 5 years, and patients do not require diagnostic studies or treatment. Red flag findings on examination that may suggest meningitis should prompt immediate lumbar puncture (LP). These include: Signs of increased intracranial pressure (eg, morning headache, vomiting, bulging fontanelle) Meningeal signs (eg, nuchal rigidity) Prolonged altered mental status (ie, postictal period >10 min) Petechial rash This febrile patient has prolonged altered mental status following a seizure. Her abnormal neurologic examination (ie, responsive only to painful stimuli 1 hour after seizure) warrants LP to assess for CNS infection. (Choice A) Evaluation for meningitis may be also indicated for a seizure in a premature infant with an underlying neurologic condition (eg, ventriculoperitoneal shunt) that increases the risk of CNS infection. Birth history in a patient with no chronic medical problems (as seen here) does not affect the decision to perform LP. (Choice B) Prolonged (>30 min) or recurrent seizures without return to neurologic baseline are associated with a higher risk of an underlying CNS infection. This patient's 7-minute seizure duration does not warrant LP. (Choices C and D) High fever and family history of febrile seizures are risk factors for developing a febrile seizure but do not change management. Educational objective: Most convulsions in the setting of fever in young children are benign (ie, febrile seizure). However, meningitis should be suspected in patients with nuchal rigidity, headache, bulging fontanelle, and/or prolonged altered mental status. Lumbar puncture is warranted in these cases. References: Recovery of consciousness following acute symptomatic seizures due to central nervous system infections in children. (http://www.ncbi.nlm.nih.gov/pubmed/22352298) Neurodiagnostic evaluation of the child with a simple febrile seizure. (http://www.ncbi.nlm.nih.gov/pubmed/21285335)

A 12-Month-Old Girl Is Brought to the Emergency Department by Ambulance