Status epilepticus in an 18-month-old child at 35,000 feet

Several years ago I was flying back from England to the U.S.  About halfway across the Atlantic the crew requested the aid of a physician for an emergency.  Despite it being a packed 747, no one answered the initial call. I decided to walk up to see what was going on and if I could provide assistance.  In the galley an 18-month-old child was in obvious status epilepticus and her mother did not speak English, so no past history could be obtained.  The child had a fever but had been seizing for an estimated 5 minutes.  She continued to have generalized convulsions and was unresponsive for several additional minutes.  The emergency medical kit on board did have oxygen, a manual blood pressure monitor, a small gage IV, and intravenous diazepam. It also had an endotracheal tube that was only designed for patients above 8 years of age.  With the help of a nurse and an adult nephrologist who joined us, we were able to establish an IV and further observations demonstrated that the child appeared to be developing autonomic instability. We placed the child in the Trendelenburg position, provided IV fluids and oxygen via nasal cannula, and attempted to reduce her temperature with cool clothes but the seizure continued.

At this point an intervention with the intravenous diazepam was indicated, but given her condition we were concerned that it would suppress her respirations and we did not have any providing artificial ventilation.  Attempts to reach ground control medical support were not successful, as we over a region of the North Atlantic Ocean near Greenland.  Unfortunately she was approaching the theoretical limit for irreversible brain injury secondary to status epilepticus of 15 minutes coupled with the risk of autonomic instability.  We had just decided that the IV diazepam was our best option when the child finally stopped seizing.   She remained obtunded but appeared to have asymmetric lateralized tone asymmetries.  The seizure activity returned almost immediately but was limited to short focal seizures involving her left upper extremity.

Through the attendant we directed the pilot to land at the nearest destination with medical services that could accommodate a critically ill child.  We were informed that ground control had been reached in Montreal and they were questioning the need for us to alter our course based on the child having a seizure.  I was summoned to the cockpit on the second floor of the aircraft and informed the ground control physician via the radio communication that the plane needed to be diverted, a process that would allow us to land three hours earlier than our targeted destination. He initially resisted, asking if this might be a routine febrile seizure.  Given that this was a topic with which I was extremely familiar, including giving prior grand rounds, I explained to him the difference between a simple and complex febrile seizure and concerns I had about a central nervous system infection.   We were granted permission to land in Montreal and the plane was met by EMT personnel. By then the child’s seizures had started to return with more vigor and she was rushed to an ambulance.  I provided my contact information to the flight personnel but was never able to learn this child’s fate.  I am hopeful that if there was an underlying sinister process that the child received medical attention in time to make a difference.   I am also thankful to the crew, and to the nurse and other physician who joined me to care for this child.

Author: Michael Stearns, MD