Lauren Kinneman DO, Inova Fairfax Medical Center
With Eiman Abdulrahman MD, Children’s National Medical Center

The Case

2 year-old previously healthy girl presents to your ED with concerns for an afebrile seizure. The seizure activity began at home, consisted of eye deviation and body stiffness with arm flexion. 911 was called, and the patient was still seizing on arrival. She was given Ativan to stop the seizure, which lasted around 15-20 minutes total. En route to the ED she seized again and was given a 2nd dose of ativan. On arrival, the patient is altered. Her right arm keeps reaching to left, left arm is not moving, and she has occasional lip chewing/smacking movements.

No known head trauma or ingestions. Her older sibling has gastroenteritis and fever.

ROS: One episode of emesis today. No fevers, rash, constipation. No prior neurological symptoms (weakness, gait change, headache).

PMH: none, vaccines up to date

Family Hx: no family hx of seizures

Exam: T 100.8, HR 182, RR 20, BP 87/50
General: Altered, eyes closed, lip smacking chewing motion
HEENT: PERRL pupils 3-4mm, TMs clear bilateral, no oral lesions
CV: tachycardic, RR, no murmurs or gallops
Resp: CTAB
Abd: soft ND, +BS, no HSM
Neuro: altered, left arm limp, right arm keeps reaching to the left

Initial glucose 117

Question for you:

IV access is obtained and a keppra load is given. Post keppra load, the lip movement stops.

Labs were sent after IV placement. Electrolytes were normal. LFTs, CBC and CRP and urine drug screen pending. Head CT obtained and showed no abnormality.

One hour into the ED stay, the patient showed no further seizure activity and was beginning to return to her baseline mental status.

Another question:

The patient’s mental status normalized in the ED around the 2 hour mark, and it was determined that patient would be admitted to the floor. Prior to admission, the patient spiked a fever to 103F.
She is not complaining of neck pain, and she has no nuchal rigidity.
Her CBC showed WBC 18k, normal differential, no bands. CRP 4.1. Her LFTs and urine drug screen were normal.

Two more questions:

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