Bug Eyes

[jwraider]

So this was not my patient. The PT came in by ambulance code 3 return while I was writing my PCR. I'm going to present it though as if you were on scene with the PT and were running the call as a 1:1 Paramedic without access to all the good stuff the hospital has (except medical control I guess but that's me so it wont get you too far!)

Also I'm very busy this week so I will present the entire case and everyone can just give us their entire call/impression and I will come back and try to answer questions.

Dispatch: 1 y/o Seizures

General: 10 mins to local ED, pediatric hospital available via helicopter only. 2pm on 75 degree sunny day.

Crew: You plus 1 EMT and an ALS engine company that arrives just after you.

You go on scene and you're at an apartment building in a low income area. Moms boyfriend meets you at the door and says "yeah, he's been shaking and he's not acting right". As you enter the living room mom is frantic and in tears, you see a 2 month old infant on the couch in a diaper only crying. Mother states: "I took him to the ER this morning because he had a seizure but they sent me home with tylenol and said he was fine!" She denies any Hx , Allergies , meds previous to today. She now says "He's been shaking and he won't stop crying". When asked what shaking means she says "more like twitching his arms and legs and his eyes won't close!"

Your PT is a 2month old who appears to be the right size (weight) is acting inappropriate for age (staring straight up, not tracking) and also crying and cannot be soothed. You see his belly going up and down and his color looks good but he feels hot. Mom says he has had a fever.

So what do you do right now?

You're now either still in the house (because you're somewhat brave) or in the ambulance. You're hooking the PT up to the monitor and taking a closer look. Mom and Boyfriend will no longer be able to provide much info except to deny pertinent negatives/positives (no vomiting, coughing, diarrhea, ate normally up until this morning, plenty of wet diapers until this morning, no trauma, no exposure to disease/sickness)

LOC - Altered, eyes are open but the PT is is just crying and staring up. No response to mother.

A- Airway is intact

B- Irregular, "wet" sounding lungs in all fields

C- Brachial @ 180, regular. Sinus Tach

Skin - normal color, hot, not wet

SP02 100% Room air

Sugar: 157

You tell the engine medic that the baby is breathing irregularly. He asks "How do you know that?" You say: "I can't tell the pattern but the speed keeps changing and ...."

The baby is now apneic.

Only change to above vitals:

Baby is now not crying

Baby is not breathing

(Pulse and skin do not change)

So what do you do right now?

30 seconds later the baby is breathing again, you're not sure if what you did caused that but it's breathing (so you can start breathing again now FYI). You're now Code 3 to the hospital (local? helicopter?). let's just say you're awesome and you get an IV right away. You're 5 minutes out and call in a report and sit back and try and collect your thoughts and you notice more as you do your detailed physical exam or focused exam just like national registry taught us!

The PTs eyes are bulging out. He looks like he's very interested in whatever is happening on the ceiling but they are obviously way larger and protruding say "like bug eyes". His head looks otherwise normal (right size, fontanels seem almost closed but aren't bulging). All other physical features seem to be WNL.

The PT is apneic again just prior to arrival.

So what do you do right now?

This spell lasts about 30 seconds again. As you walk into the ED bay the Doctor is there to meet you (yay!) and asks: "So what do we have?"

So what do you do right now?

Hope this is interesting and thought provoking I don't have the diagnosis. I know what the initial treatments and assessments were and that the baby was quickly transferred out to a children's hospital. I'll check back and add this info later I'm interested to know how you guys would handle this call and what you think is wrong with the baby. My line of thinking is it's easy to get technical and complicated here but what if you were really on this call?? How would you approach it in a simple manner so you could react and get the right stuff done and still understand what physiological dangers existed.

[Eydawn]

I've got a total stab in the dark, spurred by something in my brain that remembered hearing about bulging infant eyeballs and thyroid disorders...

Could it possibly be Graves disease? (Hyperthyroidism, essentially) That's a cause of bulging eyes in infants, and according to some of the literature I read while thinking about this case, it happens due to macrophage infiltration behind the eyes (an autoimmune response). I don't know how that would factor in with the fever. It does, however, explain the bulging eyes and staring, glazed gaze. It can cause premature closing of the fontanelles, and if the thyroid gland is enlarged it could cause pressure on the windpipe, and positionally account for periods of apnea.

What would I do? I'd monitor airway intently and be prepared to manage it aggressively. I would also use some lubricating eyedrops on the kiddo's eyes to protect them. I would paint the picture for the doctor just like you painted it in this scenario.

Definitely a weird one.

Wendy

CO EMT-B

[DartmouthDave]

Could be Double Whammy Syndrome:

Double Whammy Syndrome

No.....just kidding. =)

My experience with babies is quite limited. So, I am venturing into unknown territory here.

The infant was seen in the morning in a ED and had a fever and seizure. Ok....nothing too alarming there.

Now, a few hours later `bug eye` and abnormal eye movement. Maybe the mother or the boyfriend (or both) got overwhelmed by the fussy baby and shook the little guy? Shaken Baby Syndrome? It is my understanding that SBS infants can appear quite normal in most regards.

• Bulging eye = Elevated ICP

• Abnormal Breathing Patterns = ICP

Interested in seeing what the outcome was in this one.

[jwraider]

Those are some good differentials but not exactly what the Doctors were thinking initially atleast with their assessment and treatments. I'll post what those were later.

Remember seizure activity was never confirmed but can't be ruled out either.

[rat115]

If there's no signs of trauma to support shaken baby syndrom, I'd be wondering about something metabolic.

With the BGL being 157 makes me wonder about the possible onset of diabetes. (Family hx???) Suddenly not eating, voiding, fever,and lethargy that day. Seizure and cebrial edema can be s/s of DKA, especially in little ones. The inconsolable crying can also be a s/s.

On a personal note, I saw a 14 month old who was brought in with a metabolic disorder (body unable to digest fats properly). She started out much the same way that you've described this one except for the BGL.

[HERBIE1]

Not my forte, but I would be thinking some type of metabolic issues. Baby feels hot- initial thinking was febrile seizure. Field Tx would be supportive, O2, IV, and have anticonvulsant ready PRN. Eyes bulging is strange, but I have seen that in simple febrile seizures too.

BGL isn't a real concern to me, but periods of apnea still suggest some type of seizure activity. Possible mass- need CT, blood cultures, complete lab work up, UA, lumbar puncture to rule out any CNS issues/infections.

I hate pediatric calls- scary, too many variables, and they cannot tell you what's going on.

Other possibilities- accidental ingestion of a chemical, medications, illicit drugs, etc.

[DartmouthDave]

Hello,

Man.....I missed the BLG in the first post!

My bad.

[jwraider]

This is my guess: increased intercranial pressure because of irregular breathing.

Maybe this ?

Encephalitis

MD started treating with antibiotics and was doing a lumbar puncture when I left.

[Richard B the EMT]

Baby feels hot- initial thinking was febrile seizure.

Here, I concur.

Due to the changing speed of breathing, I'm thinking CheneStokes (spelling?) Syndrome, but I have insufficient data to determine cause.

[Kiwiology]

Aw bloody hell I am not a paediatrician .... where is Arizona Robbins when you need her?