A 10-week-old girl is brought to the emergency department after developing abnormal movements of the arms and legs. This morning, the patient developed a fever and had 3 episodes of emesis. An hour ago, she had sudden rhythmic jerking of the arms and legs, which stopped within 4 minutes. The patient was transported to the emergency department via ambulance and was sleepy during the trip. She has no chronic medical conditions, and vaccinations are up to date. Temperature is 39.3 C (102.7 F), pulse is 160/min, and respirations are 44/min. The patient appears drowsy on examination. The anterior fontanelle is open and full. She has a weak suck and decreased tone. The tympanic membranes and oropharynx are unremarkable. The neck is supple. Cardiac examination reveals tachycardia without murmurs. The lungs are clear bilaterally. The abdomen is soft with normal bowel sounds. Skin examination is normal. Which of the following is the best next step in management of this patient?

Question

A 10-week-old girl is brought to the emergency department after developing abnormal movements of the arms and legs.  This morning, the patient developed a fever and had 3 episodes of emesis.  An hour ago, she had sudden rhythmic jerking of the arms and legs, which stopped within 4 minutes.  The patient was transported to the emergency department via ambulance and was sleepy during the trip.  She has no chronic medical conditions, and vaccinations are up to date.  Temperature is 39.3 C (102.7 F), pulse is 160/min, and respirations are 44/min.  The patient appears drowsy on examination.  The anterior fontanelle is open and full.  She has a weak suck and decreased tone.  The tympanic membranes and oropharynx are unremarkable.  The neck is supple.  Cardiac examination reveals tachycardia without murmurs.  The lungs are clear bilaterally.  The abdomen is soft with normal bowel sounds.  Skin examination is normal.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d5ee_3dd6_bc81_4b4a75e4adba_MD0003_00 In young children, seizure in the setting of fever is most commonly due to febrile seizures. However, this condition must be distinguished from meningitis, a life-threatening infection. Simple febrile seizures are typically benign and triggered by fever due to a viral illness in children age 6 months to 5 years. Generalized tonic-clonic movements last <15 minutes, with a brief postictal period (<10 min). Laboratory evaluation and imaging are not required; diagnosis is clinical. In contrast, children with the following alarming examination findings require immediate lumbar puncture (LP): Signs of increased intracranial pressure (eg, morning headache, vomiting, bulging/full fontanelle) Meningeal signs (eg, nuchal rigidity) Prolonged altered mental status (ie, postictal period >10 min) Petechial rash In addition, aside from seizure and fever, young infants may lack other typical physical findings of meningitis (eg, nuchal rigidity). Therefore, patients outside of the range of typical febrile seizures (ie, 6 months to 5 years), such as this 10-week-old patient, should be evaluated for meningitis. Other considerations in the decision to perform LP include current antibiotic therapy, which can mask meningitis symptoms, or incomplete immunization history. Therefore, in addition to seizure, this patient's age, hypotonia, full fontanelle, and prolonged drowsiness warrant urgent cerebrospinal fluid evaluation. (Choices A and B) Electroencephalography is typically warranted for seizures that are prolonged, recurrent, or focal. Benzodiazepines (eg, intravenous lorazepam) are usually administered for generalized, convulsive seizures lasting >5 minutes. This patient had a single, generalized seizure and is no longer clinically seizing, making these interventions unwarranted. (Choice D) Neuroimaging should be performed in patients with focal neurologic abnormalities or a closed fontanelle to assess for an underlying space-occupying lesion, which can increase herniation risk during LP. This infant's open fontanelle increases compliance of the skull, which minimizes risk of herniation and makes imaging prior to LP unnecessary. (Choice E) Reassurance and discharge are appropriate management options for simple febrile seizure in children age 6 months to 5 years. Infants age <6 months with fever and seizure require further evaluation due to increased risk of meningitis without localizing signs. Educational objective: Seizure in the setting of fever is most commonly due to benign, febrile seizures in children age 6 months to 5 years. Infants age <6 months should undergo lumbar puncture (LP) because they may lack other typical findings of meningitis (eg, nuchal rigidity). Additional features warranting LP include signs of increased intracranial pressure and prolonged altered mental status. References: Need for lumbar puncture in children younger than 12 months presenting with simple febrile seizure. (http://www.ncbi.nlm.nih.gov/pubmed/27404463) Febrile seizure: risks, evaluation, and prognosis. (http://www.ncbi.nlm.nih.gov/pubmed/30932454)

A 10-Week-Old Girl Is Brought to the Emergency Department After