Refer to the paediatricians immediately

You call the paediatric doctors at the local hospital and they agree to see him in the emergency department (ED). You tell the mother that the team at the hospital will take good care of Rory. She thanks you for you time and care.

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You are now the attending paediatric trainee in the Emergency Department (ED). You are called urgently to the resuscitation area where there is a 4 month old infant who is having a seizure and being attended by the resus team. He was waiting to be seen having been referred by his family doctor for irritability. Shortly after triage he started fitting so was moved into the resus area. He is in the ‘recovery’ position, has an oxygen mask on him, and has been attached to monitoring. You request that he been give rectal diazepam while venous access is established.

His mother is very frightened, saying that he had been a little unwell with a cold, that the doctor said he might have a chest infection, that he has had all his immunisations, so you came to the hospital, that he had started staring, then his eyes rolled up and he started shaking all over and that he is still shaking.

The resus nurse tells you that his capiliary blood glucose is 5.6 mmol/L. A cannula is sited and you examine him:

HR 170/min, RR30/min, SaO₂ 95% in mask oxygen, BP 95/45 mmHg

Airway clear

Chest moving well, large airway inspiratory crackles

Heart sounds normal, capiliary refill 3-4 seconds

Abdomen soft

Moving all limbs rhythmically 3 beats/sec.

Anterior fontanelle full

Unresponsive.

He is given intravenous lorazepam and shortly after the seizure terminates. He remains stable from a cardiorespiratory point of view. The resuscitation team smile and leave you to continue the management.

Some blood tests that were sent on admission now have results available:

Hb       103 g/L

Wcc    16.3 x 10⁹/L

Plats    341 x 10⁹/L

Urea    3.8 mmol/L

Na       141 mmol/L

K          4.6 mmol/L

Creat   42  micromol/L

Urine is sent for microscopy and culture.

A mobile chest radiograph is also arranged.

It is twenty minutes now since his seizure terminated. You review him and take a history from his mother, who is now less distressed.

He was born at term normally. He is her first baby – it was a surprise for her and her boyfriend but she was very pleased that she was having a baby. He has been well up to this episode, and has had all the required immunisations. He is beginning to use his hands now, smiles, and follows moving objects with his eyes.

He was well up until the last 3 days, when he developed a runny nose and then a cough. She does not think her son has had a temperature. Since then he has been increasingly irritable and she cant seem to settle him. Feeding is not consistent and regular like it was before.

She has also noted a new mark on his skin and wonders if it is ringworm. She looked it up on the internet. He has two other birthmarks.

He is still very sleepy and barely responsive to pain. His respiratory rate is 30/min, temperature 37.4C and HR 120/min, but otherwise his examination is unchanged.

The new marks:

The birth marks:

What would you like to do now?