PEDIATRIC ORTHOPEDIC DISORDERS 359 Diagnosis: A low-grade fever and slightly elevated ESR may be present. Findings of a significant fever and ESR are more suggestive of a septic hip. Plain film may show joint space widening. Evidence of effusion on ultrasound is more suggestive of a septic joint which can be differentiated from synovitis with arthrocentesis. Management: The treatment consists of bed rest and NSAIDs. There is some association with later devel- opment of Legg-Calve-Perthes disease (see Table 14-26). TABLE 14-26 COMMON PEDIATRIC ORTHOPEDIC CONDITIONS DISEASE DEFINITION FEATURES TREATMENT Nursemaid elbow Radial head subluxation Arm held pronated in slight flexion Supination and flexion or hyperpronation Legg-Calve-Perthes Ischemic necrosis of the femoral head Pain, limp, limited ROM in the 4–8-year-old Confirmed on x-ray; treated with NSAIDS, rest and physical therapy Slipped Capital Femoral Epiphysis Femoral head slips posterior and inferior to the femoral neck Hip or knee pain, limp, or limited ROM in the heavy adolescent Non-weight bearing and surgical repair Osgood-Sclatter Tibial tubercle apophysitis Pain and swelling over the tibial tubercle in active young adolescents NSAIDS and rest; usually self-limited Septic arthritis Infection in the joint space Most common in children younger than 4-years-old Fever, limp, decreased range of motion Knee is most commonly affected Hip next most common, held flexed and externally rotated Widened joint space on x-ray, elevated ESR, CRP, and WBC are suggestive, but infection cannot be ruled out without synovial fluid gram stain and culture. Treatment is antibiotics and surgery Toxic synovitis Noninfectious inflammation in the joint space (most commonly hip) Hip pain, limp, decreased ROM, but nontoxic child History of recent URI All studies are normal–diagnosis of exclusion Pediatric Orthopedics FRACTURE TYPES Torus fracture (buckle fracture). This is a compression fracture of long bone typically occurring near the metaphysis. The typical mechanism is a fall on an outstretched hand. The periosteum and cortex remain 360 CHAPTER 14 / PEDIATRICS intact, so the bone does not deform. This fracture does not require reduction and is managed with immobilization. Greenstick fracture. This is an incomplete fracture on the tension side of the metaphysis. As opposed to a torus fracture, the perisoteum does not remain intact. The typical mechanism is a fall backwards (with arm twisted) on to an outstretched hand. In greenstick fractures of the distal ulna and radius up to 30 ◦ of angulation is acceptable in infants before reduction is warrented. While in children only 15 ◦ is tolerated. If the degree of angulation exceeds these limits, reduction is performed with slow constant pressure to reverse the plastic deformity until the dorsal cortex is also broken. The limb (usually forearm) should then be immobilized with a cast or splint (see Tables 14-27 and 14-28, Figure 14-1). Salter-Harris: S A L T S = straight through I A = above II L = lower III T = through IV III III IV V –FIGURE14-1— Salter Harris classification. Source: Reprinted from Meyer K, DeLaMora P (eds). Last Minute Pediatrics: A Concise Review for the Specialty Boards. McGraw-Hill, 2004, Figure 18-2, p. 349. PEDIATRIC ORTHOPEDIC DISORDERS 361 TABLE 14-27 COMMON PEDIATRIC FRACTURES FR ACTURE FEATURES TREATMENT Supracondylar fracture Mechanism is fall on an outstretched arm with hyperextension of the elbow Posterior angulation of the distal fracture fragment occurs frequently Neurovascular complications are common including Volkmann contracture, injuries to the radial, median, ulnar, and anterior osseous nerves Immobilization with a long arm posterior splint Admission to watch for compartment syndrome Distal radius fracture Most common fracture in children Treatment depends on Salter–Harris classification Suspected Salter I fractures should be immobilized and later re-evaluated Toddler’s fracture Oblique non-displaced fracture of the distal tibia in patients 9–36 months old Occurs with low energy mechanism such as fall while walking or running Immobilization with a splint Clavicle Most are greenstick injuries of the midshaft Treatment is a sling Neurovascular injuries are rare TABLE 14-28 SALTER-HARRIS CLASSIF ICATION I Sheering mechanism where fracture follows the epiphyseal (growth) plate II Along the epiphyseal plate with extension into the metaphysis III Along the epiphyseal plate with a portion of the epiphysis separated—requires early reduction IV Fracture crosses the epiphysis, physis, and metaphysis—requires early reduction and can interfere with growth. V Compression injury due to axial loading—severe injury to the growth plate due to disruption of blood supply to epiphysis. 362 CHAPTER 14 / PEDIATRICS PEDIATRIC NEUROLOGY AND NEUROSURGERY Febrile Seizure Definition: A simple febrile seizure is a generalized seizure associated with a fever lasting less than 15 minutes occurring only once in a 24-hour period. A complex febrile seizure is a seizure lasting longer than 15 minutes or occurring more than once in a 24-hour period. Etiology: The exact cause of febrile seizures is unknown. There is increased risk of developing febrile seizures in families with a history of febrile seizure. However, there appears to be no relationship to the degree of fever and risk of seizure. Patients with febrile seizures have a higher incidence of developing epilepsy. Clinical Presentation: With a simple febrile seizure, children are usually brought to the ED after the seizure has stopped. Children display symptoms of as accompanying febrile illness such as otitis media or URI. Management: In a child who had a simple febrile seizure and returns to baseline mental status and has no focal neurologic deficits, management should be the same as if the child had not had a seizure. Hypoglycemia and toxic ingestion should be considered and ruled out. Diagnostics studies should be tailored to the patient’s age and symptoms. A seizure is rarely, if ever, the sole presenting symptom of meningitis. Patients who do not return to baseline or who have a neurologic defect warrant a full septic work-up. Complex febrile seizures warrant a more extensive work-up. Active seizures can be treated with benzodiazepines. Ventricular Shunt TAB LE 14- 29 VENTRICULAR SHUNT MALFUNCTION SHUNT OBSTRUCTION SHUNT INFECTION SLIT VENTRICLE SYN DROME Presentation Evidence of increased ICP: vomiting, headache, ataxia, papilledema Abdominal pain Usually occur within 6 months of placement. Present with fever, headache, meningismus, abdominal pain. May also have shunt obstruction Presents like shunt obstruction, but is most likely due to chronic over-shunting Occurs late after shunt placement CT Findings Head CT shows ventriculomegaly compared with previous scans Head CT shows no change from previous scans Head CT reveals slit-like ventricles Treatment Neurosurgical consultation Neurosurgical consultation Antibiotic coverage against Staphylococcus species Diagnostic tap of the shunt reservoir Neurosurgical consultation, although most are managed medically GENITOURINARY COMPLAINTS 363 GENITOURINARY COMPLAINTS Urinary Tract Infection Clinical Presentation: Symptoms are highly variable; therefore this diagnosis should always be sus- pected in the febrile or irritable child. Symptoms may include abdominal pain, vomiting, fever, and urinary complaints. E. coli is the most common pathogen, except in newborns, in which Klebsiella predominates as the most common pathogen. Other organisms include Enterobacter, Proteus, Morganella, Serratia, and Salmonella. Treatment: It is recommended that infants younger than 3 months are admitted because of the risk of bacteremia and sepsis. Older babies and children who are well appearing can be managed with oral antibiotics. Testicular Torsion Etiology: Testicular torsion is caused by abnormal fixation of the testis within the tunica vaginalis. This creates the “bell clapper” deformity and predisposition of the testis to twist within the scrotum. Clinical Presentation: The patient will present with sudden onset of severe scrotal pain and swelling. Finding may include a high-riding testicle, transverse lie, and absence of the cremaster reflex. Salvage rates drop significantly after 8 hours of torsion. Torsion of the appendix testis presents with a painful testicle with minimal swelling, normal lie, and the pathognomonic “blue dot sign.” Diagnosis: The diagnosis is made primarily based on history and physical and can be confirmed with color flow Doppler ultrasound or testicular scintography. Ultrasound is also able to document normal anatomy and exclude any mass lesions that might have precipitated the torsion. However, surgical salvage should not be significantly delayed for imaging. Zipper Injuries This type of injury is most common in uncircumcised boys ages 3–6 years. The zipper is released by cutting the median bar of the zipper. Anesthesia is generally not needed. CHILD ABUSE Child abuse should be suspected in cases of injury or illness inconsistent with either the history or age of the child. Multiple injuries and delay in seeking medical treatment are also red flags. The role of the physician is not to prove cases of abuse but rather to report, treat, and thoroughly document findings (see Table 14-30). REFERENCES 2005 American Heart Association Guidelines (AHA) for Cardiopulmonary Resuscitation (CPR) and Emergency Car- diovascular Care (ECC) of Pediatric and Neonatal Patients: Neonatal Resuscitation Guidelines Pediatrics vol. 117 May 2006, pp e1029-e1038 Barkin RM. Pediatric Emergency Medicine: Concepts and Clinical Practice. 2nd ed. St. Louis, MO: Mosby, 1997. Brousseau T, Sharieff GQ. Newborn Emergencies: The First 30 Days of Life. Pediatr Clin North Am Feb 2006;53(1):69– 84. Brown K. The Infant With Undiagnosed Cardiac Disease in the Emergency Department. Clin Pediatr Emerg Med Dec 2005;6(4):200–206. 364 CHAPTER 14 / PEDIATRICS Claudius I, Fluharty C, Boles R. The Emergency Department Approach to newborn and Childhood Metabolic Crisis. Emerg Med Clin North Am Aug 2005;23(3):843–883, x. Colletti JE, Homme JL, Woodridge DP. Unsuspected Neonatal Killers in Emergency Medicine. Emerg Med Clin North Am Nov 2004;22(4):929–960. Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. 4th ed. Philadelphia, PA: Lippincott, Williams & Wilkins, 2002. Kestle JR. Pediatric Hydrocephalus: Current Management. Neurol Clin Nov 2003;21(4):883–895, vii. Marx JA, Hockberger RS, Walls RM, Adams J, Rosen P. Rosen’s Emergency Medicine: Concepts and Clinical Practice./ 6th ed. Marx JA, Hockberger RS, Walls RM, et al. (eds). Philadelphia, PA: Mosby/Elsevier, 2006. Meyer K, DeLaMora P. Last Minute Pediatrics. New York: McGraw-Hill, 2004. Moore EE, Feliciano DV, Mattox KL. Trauma. 5th ed. New York: McGraw-Hill, 2004. Strange GR, American College of Emergency Physicians. Pediatric Emergency Medicine: A Comprehensive Study Guide. 2nd ed. New York: McGraw-Hill, 2002. Strange GR, American College of Emergency Physicians. American Academy of Pediatrics. APLS: the Pediatric Emer- gency Medicine Course. 3rd ed. DallasTX: American College of Emergency Physicians, American Academy of Pediatrics, 1998. Tintinalli JE, Kelen GD, Stapczynski JS, American College of Emergency Physicians. Emergency Medicine: A Compre- hensive Study Guide. 6th ed. New York: McGraw-Hill, , 2004. Woods WA, McCulloch MA. Cardiovascular Emergencies in the Pediatric Patient. Emerg Med Clin North Am Nov 2005;23(4):1233–1249. TAB LE 14- 30 PHYSICAL FINDINGS OF CHILD ABUSE PHYSICAL FINDING PATTERN COMMENTS Bruising Buttocks, lower back, genitalia and lower thighs, neck, and earlobes Hand and finger marks from grabbing appear oval Bruises can be confused with Mongolian spots Fractures Corner, bucket-handle, or metaphyseal fractures resulting from violent grabbing or twisting of the extremity Rib fractures occur from squeezing of the chest when shaking Skeletal survey may reveal healing fractures of various ages Burns Most common are immersion burns involving both legs and buttocks and will be circumferential Multiple small circular burns should suggest infliction with a cigarette Accidental burns occur from splashes or grabbing hot objects The burns involve a single area Head injuries Mechanisms include shaking or slamming Classic findings are subdural hematoma, subarachnoid hemorrhage, and intraparenchymal injury May also see skull fractures Most frequent cause of death in abused children Suspect in the child who is not yet ambulatory but has a head injury CHAPTER 15 PSYCHOBEHAVIORAL DISORDERS ADDICTIVE B EHAVIOR Alcohol and Drug Dependence Definition: Alcohol or drug dependence is defined as a maladaptive pattern of use associated with three or more of the following criteria: r tolerance r withdrawal r substance taken in larger quantity than intended r persistent desire to cut down or control use r time is spent obtaining, using, or recovering from alcohol or drugs r social, occupational, or recreational tasks are sacrificed r use continues despite physical and psychologic problems Clinical Evaluation: A standard screening tool for alcoholism used in the Emergency Department is the CAGE questions. These are: “Have you ever felt you should Cut down on your drinking? Have people Annoyed you by criticizing your drinking? Have you ever felt bad or Guilty about your drinking? Have you ever had a drink first thing in the morning (Eye opener) to steady your nerves or get over a hangover?” Answering “yes” to two of these questions is a strong indication for alcoholism; answering “yes” to three confirms alcoholism. Treatment: Once a patient has been presented with their diagnosis and is prepared to stop inappropriately using drugs or alcohol, there are different approaches for treatment. For the patient with mild withdrawal symptoms they may be managed with outpatient referral, and referral to alcoholics or narcotics anonymous. For those patients with more severe withdrawal symptoms, a history of withdrawal seizures, depression or suicidal ideation, severe coexisting medical orpsychiatric conditions, or previous failure to outpatient therapy, hospitalization should be considered. Nonhospital residential therapy is appropriate for patients who need to be removed from their environment but do not require 24-hour medical coverage. Drug-Seeking Behavior Definition: Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that 365 Copyright © 2007 by The McGraw-Hill Companies, Inc. Click here for terms of use. 366 CHAPTER 15 / PSYCHOBEHAVIORAL DISORDERS has not been appropriately managed. Criteria for determining the risk of drug-seeking behavior have been reported (Table 15-1). Pain Management Treatment: For patients with identified chronic pain, some cautions should be noted. Opioids produce euphoria in some patients providing the motivation for abuse. In some patients who are not seeking the drugs for the euphoric properties, it is the self-reinforcing properties of opioids that cause the drug-seeking activities. Meperidine (Demerol) poses a very serious problem when it comes to drug-seeking patients. Meperidine has been shown to be the most intoxicating of the opioids, producing 67% more drug high than morphine at equivalent doses. Management Strategies: Narcotic contracts and pain management letters may be used to prohibit the administration of narcotics to certain patients without authorization from their primary care physician. Compassionate refusal has been described as a method of denying patients narcotic medications while still appearing to care has been shown to reduce repeat ED visits. The use of long-acting opioids such as long- acting morphine or methadone may also be management options as these formulations give less of the immediate euphoric effects while reducing the effects of withdrawal. TAB LE 15- 1 INDICATIONS OF POSSIBLE DRUG SEEKING BEHAVIOR 1. Alteration or forgery of prescriptions 2. Multiple excuses regarding lost, stolen, or damaged medications 3. Abusive or threatening behavior when one is denied medications 4. Multiple unscheduled episodes involving requests for controlled medications 5. Giving fraudulent information to clinical or administrative staff 6. Seeking care simultaneously from multiple providers 7. Noncompliance with follow-up care plans Eating Disorders ANOREXIA Definition: Anorexia is a disorder of eating characterized by a weight <85% of ideal body weight, fear of fat- ness, distortion of body image,and amenorrhea infemales. The ratioof male tofemales with thisdisorderis 1:9. BULEMIA Definition: Bulimia nervosa is an eating disorder characterized by recurrent eating binges of 2 times per week for 3 months or more, excessive preoccupation with weight and shape, and measures to reduce weight gain from the binges. Prevalence of bulimia in adult women has been estimated to be as high as 2–3%, and in adolescent males 0.1–0.7%. These patients may be normal or overweight, which can make them hard to distinguish as eating disorder patients. Clinical Presentation: The presentations ofpatients with eatingdisorders varygreatly in theED. Extreme weight loss and starvation accompanied by malaise and fatigue secondary to malnutrition is a common complaint when these patients present to the ED. The patients may complain of constipation or obstipation. Parents may complain that a child eats normal amounts and has lost weight, or eats excessive amounts and is not gaining weight. They may have psychiatric as well as medical presentations. The psychiatric presentations of patients with eating disorders include: ADDICTIVE BEHAVIOR 367 r Anxiety disorder that can occur in up to 60% of eating disorder patients. r Mood disorders and potential suicidal ideation or attempts. Major depression has lifetime prevalence as high as 80% in eating disorders. r Substance abuse disorders such as those resulting from stimulants and amphet amines are common in attempts to limit oral intake. Alcohol binges and ipecac abuse are not uncommon in this group of patients. r Cognitive disorder secondary to starvation or caloric restriction. The medical conditions that patients with eating disorders present with are quite varied. Even the method of purging behavior can result in differing patterns of electrolyte abnormalities (see Tables 15-2 and 15-3). TABLE 15-2 SERUM ELECTROLYTE ABNORMALITIES ASSOCIATED WITH PURGING BEHAVIORS IN BULEMIA PU RGING BEHAVIOR SODIUM POTASSIUM CH LORIDE B ICARBONATE Induced vomiting variable ↓↓↑ Laxative abuse ↑↓ variable variable Diuretic abuse ↓↓ ↓ ↑ TABLE 15-3 MEDICAL CON DITIONS OF PATIENTS WITH EATING DISORDERS SYMPT OMS ETIOLOGY Metabolic alkalosis Vomiting Contraction alkalosis Frequent use of cathartics Dehydration Fluid restriction Renal failure Hypothyroidism Adaptation to malnutrition Hyper/hypoglycemia Binging or starvation Bradycardia Vitamin deficiency Hypotension High output cardiac failure Arrhythmias Electrolyte abnormalities Neurologic disorders Mallory–Weiss tear Repetitive vomiting Superior mesenteric artery syndrome Eating after period of starvation Gastric rupture Intracranial hemorrhage Loss of gray and white matter increasing susceptibility to CNS shear injury 368 CHAPTER 15 / PSYCHOBEHAVIORAL DISORDERS MOOD DISOR DERS Bipolar Disorder Definition: Bipolar disorder is characterized by a period of sustained disruption of mood, associated with distortions of perception and somatic functioning, and impairment in social functioning. Bipolar subtype I is characterized by patients who have a history of at least one manic episode, with or without past major depressive episodes. Bipolar subtype II is characterized by patients who have a history of at least one episode of major depression and at least one hypomanic episode. A hypomanic episode is an elevation in mood, which is abnormal for the patient but does not seriously impair functioning or require hospitalization. Depression Definition: Major depression is characterized by at least four of the eight symptoms of dysphoria in Table 15-4, and must be present during at least half of the time over 2 weeks. TAB LE 15- 4 COMPONENTS OF DYSPHORIA IN DEPRESSION Sleep disturbance Loss of interest in usual activities Feelings of wor thlessness or guilt Decreased concentration or decision making Decreased energy or increased fatigue Appetite disturbance Psychomotor changes Suicidal thinking Treatment: In an acutely depressed patient, hospitalization may be necessary if the patient is at risk of doing harm to themselves or if it is felt that optimization of medication regimen or intense psychotherapy may be needed. Psychopharmacotherapy with many different agents is a mainstay of treatment in the patient suffering from major depression. Psychotherapy on an ongoing basis has also been shown to be beneficial to these patients. Suicide Risk Clinical Evaluation: Discussing ideas about or plans for suicide may relieve patients of the anxiety and guilt they may have and help establish a safe environment for full assessment and treatment. Direct assessment of the suicide risk of a patient allows for appropriate intervention that could potentially be lifesaving. Psychiatric and social history should include identifying previous suicide attempts or treatment [...]... 2000;14(2):1 37 151 Marshall GN Posttraumatic Stress Disorder Symptom Checklist: factor structure and English-Spanish Measurement Invariance J Trauma Stress 2004; 17( 3):223–230 Martini DR Delirium in the Pediatric Emergency Department Clin Pediatr Emerg Med 2004: 173 –180 Marx JA, Hockberger RS, Walls RM, et al (eds) Rosen’s Emergency Medicine: Concepts and Clinical Practice, 5th ed Vol 2 St Louis: Mosby, 2002:15 57 15 67. .. Potential by Non-Psyciatrists Using the SAD PERSONS Score J Emerg Med 1988;99:6 “Illicit Drug Abuse.” MD Consult 7 Jan 2005 (accessed 12 June 2006 www.mdconsult.com) Johnson TL Updates and Current Trends in Child Protection Clin Pediatr Emerg Med 2004;5: 270 – 275 Kaznik SR, Gausche-Hill M, Dietrich AM, et al The Death of a Child in the Emergency Department Ann Emerg Med 2003;42:519–529 Kubler-Ross E On Death... American Psychiatric Association, 2000 Anderson KE, Savage CR Cognitive and Neurobiological Findings in Obsessive-Compulsive Disorder Psychiatr Clin North Am 2004; 27: 37 47 Cantu M, Coppola M, Lindner AJ Evaluation and Management of the Sexually Assaulted Woman Emerg Med Clin North Am 2003 :73 7 75 0 Carlson MJ, Baker LH Difficult, Dangerous, and Drug Seeking: The 3D Way to Better Patient Care Am J Public... Medullary cystic disease Clinical Presentation: T A B L E 1 6 - 7 CLINICAL PRESENTATION OF CHRONIC RENAL FAILURE Treatment: Definitive treatment for CRF is dialysis, either hemodialysis or peritoneal dialysis There are multiple complications associated with dialysis (Tables 1 6-8 and 1 6-9 ) 3 87 ACUTE AND CHRONIC RENAL FAILURE TA B L E 1 6 - 7 CLINICAL PRESENTATION OF CHRONIC RENAL FAILURE CARDIOVASCULAR... structural, or physiologic abnormality (Table 1 5 -7 ) TA B L E 1 5 - 7 SYMPTOMS OF FIRST-EPISODE PSYCHOSIS IN THE EMERGENCY DEPARTMENT Delusion Hallucination Disorganized thoughts Disorganized or catatonic behavior Clinical evaluation: The initial evaluation should be focused on determining whether the patient’s functional status change is acute or part of a chronic psychiatric illness Directed questioning... presented in Table 1 5-1 0 TA B L E 1 5 - 1 0 MEDICATIONS FOR ANXIETY DISORDERS DISORDER MEDICATIONS Generalized anxiety disorder Benzodiazepines (short term); SSRI or SNRI (long term) Social anxiety disorder SSRI or MAO-I (long term) Performance anxiety disorder Beta blockers Post-traumatic stress disorder SSRI (first line); MAO-I or TCA, (second line) Panic disorder SSRI (first line); MAO-I, TCA, or clonazepam... characterized by irreversible nephron loss and scarring GFR reductions of greater than 75 % result in clinical symptoms End-stage renal disease results when renal function is diminished such that life-threatening accumulations of toxic metabolites and fluid occur Etiology: TAB LE 1 6-6 MAJOR CAUSES OF CHRONIC RENAL FAILURE 386 TA B L E 1 6 - 6 CHAPTER 16 / RENAL AND UROGENITAL DISORDERS MAJOR CAUSES OF CHRONIC RENAL... Obsessive-Compulsive Disorder: Prediction of Cognitive-Behavior Therapy Outcome Acta Psychiatr Scand 2006;113(5):440–446 Spivak HR, Prothrow-Stith D Addressing Violence in the Emergency Department Clin Pediatr Emerg Med 2003:134– 140 Stone J, Smyth R, Carson A, et al Systematic Review of Misdiagnosis of Conversion Symptoms and “Hysteria” BMJ 2005;331 (75 23):989 Epub Oct 13, 2005 Stovall J, Domino FJ Approaching... generalized edema develops and frequent infections occur Diagnosis: TAB LE 1 6-1 1 DIAGNOSTIC CRITERIA FOR NEPHROTIC SYNDROME 389 GLOMERULAR DISORDERS TA B L E 1 6 - 1 1 DIAGNOSTIC CRITERIA FOR NEPHROTIC SYNDROME Generalized edema Hypoproteinemia (decreased albumin, complement, and immunoglobulins) Urine protein-to-creatinine ratio >2 24-h quantitative urine protein level >50 mg/kg of body weight Hypercholesterolemia... for victimization Partners at risk for abuse include those on abuse substances, less educated, and with intermittent employment Victims at risk for abuse include childhood abuse victims, those with a personality disorder, and those at younger age One study found that 37% of female patients presenting to the ED for violent injury were injured by their partners It is important for the emergency physician . chemical, structural, or physiologic abnormality (Table 1 5 -7 ). TAB LE 1 5- 7 SYMPTOMS OF F IRST-EPISODE PSYCHOSIS IN THE EMERGENCY DEPARTMENT Delusion Hallucination Disorganized thoughts Disorganized. a fever lasting less than 15 minutes occurring only once in a 24-hour period. A complex febrile seizure is a seizure lasting longer than 15 minutes or occurring more than once in a 24-hour period. Etiology:. McGraw-Hill, 2002. Strange GR, American College of Emergency Physicians. American Academy of Pediatrics. APLS: the Pediatric Emer- gency Medicine Course. 3rd ed. DallasTX: American College of Emergency