Cat Scan vs. sit and wait?

[LIZPICURN]

Would like some advice. Received intubated child that seized. Reported on from night shift pt has known seizure disorder and was given phenobarbital loading dose and X1 dose of fentanyl for agitation. Reported gaggy on ETT tube and throwing up around NG tube t/o night. Pt. appropiate, pupils PERL. RN reports MD dc'd catscan stating this was a known seizure disorder and no reason to obtain test. This was somewhat suprising to me but I didn't think much of it. Plan to extubate once pt wakes up. Fairly basic assignment right? WRONG. Within AM Pt was just too sleepy to extubate. Awaiting pt to wake up more. Pt then seizes for over an hour spikes a temp. Huge doses of cerebryz and re loaded with phenobarbital. Remains seizing and finally has a brief code with no meds or compressions needed. Seizing subsides. Pupils PERL, Pt's perfusion decompensated. Placed on Dopamine. No catscan ordered. Cont EEG ordered/ Placed on pt hours later. (takes time for tech to receive order and prep pt.) Pt. Flat lined on EEG. No catscan ordered, staff feels pt. basically "under general anesthesia" from the large amount of medication given to stop seizure. ON night shift pt. blew pupils and withdrawn in AM. Any advice. Neuro assessment : Pt sleepy, Pupils PERL before seizure. Too young to really follow a command,yet responds to touch or shake/shout. Afebrile. Do you think a Catscan should have been implemented upon admission or this was just a freak thing? (Before admission to hospital pt seized, not reported how long, possible brief period of apnea with squad) Thanks. This day still remains etched in my mind and all the what if's.

[Jolie, BSN]

I probably wouldn't have gotten too concerned over the lack of a CT scan had the child "woken-up" and been extubated in the am.

But when the am rolled around, and he was "too sleepy" to extubate, the first alarm bell would have gone off in my head. An hour-long seizure accompanied by a fever, cardiac arrest, and circulatory failure would certainly have warranted a CT scan to rule out bleeding in the brain.

Placing a continuous EEG "hours later" seems ridiculously inadequate. If a flat-line EEG was not enough to prompt action by the physician, why was it even ordered?

It may not have been possible to change the eventual outcome for this child, but it seems like the medical staff missed some opportunities to at least try.

Sorry you are so disturbed by all this. I am sure you did everything within your power to help this child. God bless you for caring and trying to learn from this situation.

[veronica butterfly, ADN, RN]

So sad for the babe, yes, outcome probably wouldn't have been different no matter what tests were ordered.... but it does seem that the doc wasn't proactive in finding cause. Is the child dnr/dni or anything that would have changed the aggressiveness of treatment? Were the parents content with the doctor's orders?

I'm a nurse and a mom to a profoundly delayed boy with Lennox gastaut disorder (constant seizures of every type). Last week we were spending the day at a local children's hospital getting his wheelchair refitted. He happened to be very lethargic and having increased seizures for a couple of days. He does this when he gets sick or when he's gotten too much seizure medication. Since we were spending the whole day at the hospital sitting around waiting, I thought I'd take him down to the ER in the same hospital and have some blood work (cbc, depakote level) done to see if there was a reason for his lethargy. Very nice folks, blood work and a chest xray done were completely normal. They then asked me if I wanted a CT scan done..... I declined because in his case I really don't think there was any indication of stroke/bleed, etc. However, just goes to show you that in this hospital, a county hospital in a major city, the CT was offered almost immediately. And.... my son is dnr/dni....

You as a nurse did everything you could. God bless you for your love and concern for your patients, I know they and their parents can feel it. I'm on "both sides of the door" as a nurse and a parent of a sick guy and I thank god everyday for dedicated, caring professionals such as yourself.

[LIZPICURN]

Thanks so much for the response. My pt. was a 2 year old with no obvious delays obviously with an uncontrollable seizure disorder. Parents were accepting and thanked me for the care. My prayers go out to you with your little one. You sound like a wonderful parent and nurse.

[BittyBabyGrower, MSN, RN]

Oh, how awful. Doesn't it seem that every kid gets some type of scan for the littlest things and then when you really, really think that they need one they don't do it! It sounds like the doc dropped the ball here. I hope your next work day is a bit better.

[RunnerRN, BSN, RN]

How awful! It sounds like you did everything you could. I'm sure a CT would have been in order - like the above poster said, we scan people until they glow "just to make sure" but when someone has obvious indications, for some reason it doesn't happen.

On the same note, our peds neuro doesn't like to have CT done for new sz disorders - they feel that MRI is usually a better scan to check things out. But in this case, maybe both would have been in order - a CT to at least make sure there wasn't a bleed.

I'm glad the family is so nice; what a terrible thing to go through.