Hot Seat Case #126: 11 mo female with unresponsive episode
Posted on: February 21, 2019, by : Chisom Agbim
Chisom Agbim, MD Children’s National Medical Center
with Jennifer Chapman, MD Children’s National Medical CenterH
HPI: 11-month-old fully vaccinated otherwise healthy female presenting after unresponsive episode today. The episode was witnessed by her caretaker; however, she is brought to the ED by different caretakers. Her family states that she was being fed her small bites of crackers. She then suddenly became limp and unresponsive for 30 minutes, unsure of color change. Her caretaker did not have access to a phone and did not notify anyone of her symptoms until someone else came home to find the patient sleeping and unable to be aroused for 5 minutes. Household prescription meds include sitagliptin and metformin HCl, hydrochlorothiazide and losartan.
ROS: No fever, cough, nausea, vomiting, abdominal pain, bloody stool or diarrhea. Denies any abnormal movements or posturing during the episode. Unclear if episode was associated with color change.
PMHx: Vaccines up to date
Birth Hx: Born at 39 weeks via NSVD, no complications during pregnancy or post birth
PSHx: None
Allergies/Meds: NKDA. She does not take any medications.
Family Hx: Grandmother with diabetes and hypertension. No history of cardiac arrhythmia or sudden death. No history of epilepsy
SocHx: Lives with both parents; however, parents are out of town. Patient was left in the care of aunt and her husband (and two school aged children) for the past 3 days. Today, the patient was left in the care of grandmother.
PE: Vitals: Temp 36.6, HR 134, RR 28, BP 88/62, O2 sat 100% on RA
General: Alert. appropriate for age. cooperative.
Skin: Warm. no rash. Superficial 1 cm scratch on superficial side of right lower eyelid.
Head: Normocephalic. Atraumatic.
Neck: Supple. no lymphadenopathy.
Eye: Pupils are equal, round and reactive to light. Extraocular movements are intact. normal conjunctiva. No discharge.
Throat: Oral mucosa moist. No pharyngeal erythema or exudate. Frenulum intact.
Cardiovascular: Regular rate and rhythm. No murmurs, rubs or gallops. Normal peripheral perfusion.
Respiratory: Lungs are clear to auscultation bilaterally, respirations are non-labored.
Gastrointestinal: Soft. Nontender. Non distended. Normal bowel sounds in all four quadrants.
Genitourinary : Normal genitalia for age
Back: Normal range of motion
Musculoskeletal: Normal ROM. Normal strength throughout. No tenderness, swelling or deformities.
Neurological: Awake and alert. No focal neurologic exam. Developmentally normal. Normal coordination.
A workup is initiated including EKG, CMP, CBC urine drug screen, POC glucose with the following results:
POC glucose 112
CBC: WBC 17.7, Hgb 12.2, Hct 37.2, Plt 385
CMP wnl
Urine drug screen negative, salicylate and acetaminophen level pending
EKG normal sinus rhythm
CT head normal (preliminary read by radiology)
The patient continues to act per her usual baseline and remains stable. She tolerates 6 oz of formula in the ED. You are able to speak to her mother via phone and notify her of the results. Social work is consulted, recommendations pending. Her mother just arrived to the ED.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose
Great case! The unresponsive non-verbal child is always difficult as they can’t really give us any clues as to what happened. I’m a bit more alarmed that 2 caregivers witnessed this and were worried. It has all the sounds of an ingestion, but unlikely to have a source with UDS or other testing. Seems less likely infectious from description/vitals Agree with head CT to r/o trauma; NAT is on the differential, and I’m not sure what to make of the scratch to the eye – could definitely be cruising or walking and fall, or from an interaction with the other kids in the house where the child was staying. I think I would want a long period of observation and I woud need to feel pretty confident in mom as a caregiver to send home without an admission for longer observation.
Agree with Dr. Isbey – a healthy 11 m/o should not be unresponsive for any amount of time. Trauma and ingestion are high on the differential with infectious etiology lower down in the absence of prodromal symptoms or findings on examination. Although ingestion is high on differential, I would expect persistent or evolving findings on mental status or vital signs. I would like to see the results of the abdominal imaging as intussusception can present with intermittent mental status changes. Also, consider first time non-febrile seizure, but aside of an EEG or MRI, which can be done as outpatient, the rest of initial workup has been completed in the ED.
Agree that a prudent observation period in the ED with the mother who could point any changes in behavior is the most prudent idea, and if no changes in clinical picture, discharge with clear instructions and close follow-up.
To summarize, a healthy 11mo had a sudden-onset limp episode that began while eating. It lasted 30min. In the ED, the infant has a normal mental status, normal neurological exam, and reassuring bedside labs.
What is a differential diagnosis:
– BRUE: the definition requires that the episode last < 1 minute and that there be no concern for an alternative diagnosis. The episode lasted 30 min and there is a high concern for an alternative diagnosis including seizure and head injury. So there is no further consideration of stratifying this patient into low-risk category as given by the BRUE guidelines for well-appearing infants.
– Ingestion: certainly there are medications to be concerned with, given that the infant is at an active and curious age. There are both hypoglycemic and anti-hypertensive agents in the house. None of these falls under the ‘one pill can kill’ worry, but there still needs to be immediate attention to bedside glucose and vital signs. The next approach to the concern for ingestion includes a BMP (maybe CMP if acetaminophen of concern), Osm, ASA and acet levels, and an ECG looking primarily at intervals (QRS and QT).
– Trauma: a sudden onset episode raises concern for a brain injury. Is there any evidence for this? The facial abrasion under the eye is certainly possible in an active infant. But studies of abusive injury also note a high correlation between facial bruising and brain injury, so a young infant with a facial bruise must always have head imaging (‘if you can’t cruise, you don’t bruise’). Other points that raise my concern: why did the caretaker wait 30 minutes and not get help for an unresponsive infant. This is a situation where a mom typically runs to a neighbor’s house or drives to the closest fire station for help. In addition, I would want to know more about why the parents left an infant with a caretaker—there may be a good explanation, but not many parents leave babies when they go away.
– Seizure: as ED providers, this is always in our thought process with an episode of sudden onset. The duration could fit with a post-ictal period. Having said that, the majority of seizures have motor activity associated with them. Atonic seizures are much less common.
– Infectious: no antecedent symptoms, no fever, no physical exam findings of infection. The infant is active, alert and does not have meningismus. Given this, obtaining a blood culture or performing a lumbar puncture would be lower priority than obtaining imaging and ingestion labs.
– Abdominal pathology: commentator above included intussusception. This is a good thought, though not as high as the other concerns. Children with intussusception and lethargy usually are still lethargic in the ED, with an appearance that is out proportion to symptoms (vomited a few times, for example, but looking dehydrated).
– Mechanical: choking or aspiration. These are not described at the time of the episode and the patient has no drooling, stridor, cough or lung findings concerning for these diagnoses.
Social: again, why was the infant left with family and why did the caretaker not act with more urgency. While we see parents who parent differently from how I might parent, I still use a ‘reasonable person’ standard in my mind when I evaluate a parent’s decision. It does not seem reasonable to watch an unresponsive infant. Therefore, as the ED provider, I will probe much more into the social situation than I might otherwise.
There are 2 broad approaches to the well-appearing infant with a concerning episode: observation (in ED or in-hospital) with a minimum work-up or an aggressive work-up to cover a variety of diagnoses.
In this situation, there is too much that is very concerning by history to keep to observation only. My choice would be ingestion labs, head CT, blood and urine for infection assessment, and admission.