Acute Onset, Seizure-like activity and altered mental status


• En Route- IO attempt, IO successful, IV attempt, EKG, Versed. 4 doses (see below) totaling 6.2mg, MRH consult.
• Hospital- Vitals, IV attempt, fluid bolus via IO, Labs, Urine, planned for 1mg Ativan IV if patient starts seizing again.
• Response to treatment- IM and first IO Versed had little to no effect on patient, third dose of versed 1.5mg IO did stop seizures for a short while, 2.5mg IO versed stopped seizures upon arrival at hospital and provided for patient improvement.
• Oxygen and airway positioning moved oxygen saturation from 82% RA to 100%.
• IO attempt on Left Proximal Tibia failed, we think because the pediatric IO did not fully penetrate and failed to seat correctly. The decision was made very quickly to do a second IO attempt despite our first failure.
• The second IO required more force to get past the soft tissue to get the IO to seat but functioned very well after that.
• The patient’s airway was very positional so after stabilizing the patient, I would manually hold his head upright for most of the ride in.


• Pediatric ICU


Elliot Williams, Paramedic Woodburn Ambulance
Mark Shelton Paramedic Woodburn Ambulance


Merlin Curry, MD Paramedic University of Arizona


• Febrile seizure
• Status epilepticus
• Complex febrile seizure

Differential Diagnosis

• Seizure disorder (non-febrile)
• Febrile Seizure
• Status epilepticus
• Non-accidental trauma
• Closed head injury (intracranial bleed)
• CNS neoplastic disease (tumor) • Ingestion

Patient Workup

• EKG – Sinus tachycardia
• CBG – 125
• Patient had seizure activity, was drooling with some emesis near mouth initially when found on his side. patient had some grunting respirations, clear lung sounds.
• Eyes did not track movement, patient did withdraw from pain but was not alert.
• Left leg was noticed to be moving significantly more than right leg, even before IO’s.
• No head trauma noted, normal bumps and scrapes noted.

Key Points

• Take a moment to size up the patient and gather a history
• Suction the airway and provide oxygen, get a fingerstick and move quickly to establish IV access
• Be suspicious for ongoing seizure activity. Any abnormal movements, decreased responsiveness, mental status not improving rapidly, gaze deviation, etc. may be indications for treatment.
• Remember, you’re arriving 5+ minutes after this started at least, so if they are still seizing then it is probably status epilepticus.
• Give benzodiazepines per protocol and support the airway.
• Intubation rarely needed, but be prepared. For this case, what equipment would you want, sizes, drug dosages, etc.?

Editor’s Notes

The scene reminds me of the challenges of working on the front lines as a paramedic. More than the medicine, what struck me was the mother’s distraught state. The paramedics recognized lows sats and immediately placed a non-rebreather to address the hypoxia. A second part of this case (Case#818) will be published that includes intraosseous cannulation.

– David Spiro, ReelDx Editor


• Gender: Male
• Age: 19 months
• Height: Not Available
• Weight: Not Available


• Temperature: 101 F/38.3 C
• Blood Pressure: 80/66
• Heart Rate: 129
• Respiratory Rate: 30
• Pulse Oximetry: 83% RA

Signs and Symptoms

Mom states fever today, gave acetaminophen before coming to Mall. Mom said that based on past seizures, PCP said to wait 5 minutes and then call 911

History Medical

• Two previous febrile seizures • NKDA Social • Lives with mother


• None

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