Got a clue?

[er_nurse_tracey]

would like to know if anyone else has come across this situation. Two nights ago I had a 12 yr old male brought in by medics that I am still thinking about. Around 6 pm he began "not making sense" according to mom. By 7 pm, he had no use of his right arm, was stumbling, could not speak and did not recognize his grandmother (afterschool caregiver). Mom called pediatrician, was told to bring the boy in. On the way to the MD's office, boy suffered tonic-clonic seizure and right sided paralysis. Mom pulled over & called 911. Medic report states boy was cyanotic and hypotensive at the scene. Upon arrival to us at 8pm, BP was 80/46 with P of 122, slurred speech, right sided weakness, pupils of 7 and sluggish, oriented only to person. Since we had one of those docs on who should not be an ER doc, he did not see the child until 25 minutes later. I ordered stat head CT, routine labs plus drug screen and ETOH, blood & urine cultures. EVERYTHING came back negative. In the meantime, I called closest children's hospital to arrange for transport.

Here's my problem: by the time the doc saw him 25 min after arrival, speech cleared and the boy was oriented again, but still with blown pupils and right sided weakness. The doc summarily diagnosed an anticholinergic reaction and wanted to send the boy home. The child had no medical hx, never had a seizure, takes no meds, has no known allergies. He was driven to school by his father and mom picked him up. After school he ate a bagel and played with younger sister until sx started. Has no behavioral changes that would indicate drug use. I talked to the child's PMD and at least had him admitted to our peds floor, but we have no peds critical care. At 7AM, before I went off shift, the peds nurse told me his pupils were still at 7 and he still had right-sided weakness.

Has anyone come across these type of sx in a child before? I have been off duty since that night and am still convinced there is something neuro not picked up on the CT. I am angry since, if this was a 60 yr old male, we would be admitting to the unit with dx of r/o CVA.

Tracey

[gwenith, BSN, RN]

This is one of those suspenders and belt cases where it is better to at least have the child admitted but I agree - there is somehting neuro going on - don't forget that a CT definietely has diagnostic limitations - size of tumour and isodensity of material can give false readings not to mention problems such as vascular spasm which does not neccessarily show up on CT and yes! I have seen severe vascular spasm cause what looks like a CVA. It is extremely rare but a CVA can occur at any age. So yes! Even if this turns out to be the red herring of the year EVERY symptom you have listed points to a definite neurological problem.

[ernurse728, LPN]

Sounds like he needs an MRI of his head to see if the CT missed something.

[P_RN, ADN, RN]

I wonder if he got into a fight at school. Or even something like a shaken baby syndrome at home? My cousin had a cva at 16 and I thought that was young but this youngster definitely has neuro probs. and an MRI would seem to be indicated. Mind you it's been quite a while since I did ER.

[FsPilotMed1]

Just a thought, I could be waaaaaaaaaaay off base. What about a TIA? A friend of mine had one a while back, the symptoms sound similar. CAT scan and MRI were negative. Just thought I'd throw that out there.

Dan

[sanakruz, ADN]

My daughter had similar problem at age 3-

Flown to Stamford by chopper. MRI showed "Cerebral Infarction"

She recovered. 14 years later she started seizing again. MRI showed NOTHING! Dx: Seizure disorder....on topamax

[er_nurse_tracey]

Thanks to all of you who responded to my message regarding the boy with CVA sx. The next day, he was transferred to the regional children's hospital by his pedicatrician, who finally came in to examine the boy and realized why I was so concerned! The word we get is that the PMD suspects epilepsy, it turns out the boy's birth mother was a drug addict and this boy was a drug baby. Who knows what's ticking away in his brain. Anyway, his condition remained relatively stable during the night he spent in our hospital although sx remained unchanged. There's also going to be a chart review at our facility on this case. Thank God the child was eventually sent where he can receive the proper care.

Tracey

[AngelGirl]

Fortunate for this child that he had YOU as his nurse!!

[debbyed]

:) You did Good!!!

[gwenith, BSN, RN]

Thanks for the follow through - it is always nice to know the end of the story.

PS Congrats on a good job in difficult circumstances.