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Pediatric Seizure and SE Patient ED Care: Challenging Cases Edward P. Sloan, MD, MPH, FACEP 1.

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Presentation on theme: "Pediatric Seizure and SE Patient ED Care: Challenging Cases Edward P. Sloan, MD, MPH, FACEP 1."— Presentation transcript:

1 Pediatric Seizure and SE Patient ED Care: Challenging Cases Edward P. Sloan, MD, MPH, FACEP 1

2 Edward P. Sloan, MD, MPH Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL Edward P. Sloan, MD, MPH, FACEP 2

3 Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL Edward P. Sloan, MD, MPH, FACEP 3

4 4 Housekeeping Issues Disclosures Meeting support from UCB Pharma –Thank you Dave Riccio –IV levetiracetam, a second generation AED –May soon be an IV parenteral option in the ED Please fill out a CME form with your Please give feedback to improve our work

5 Edward P. Sloan, MD, MPH, FACEP 5 Overview Acute Pediatric Seizures Common ED problem Seizures: 6% of EMS encounters Pediatric seizures: 1% of all ED visits Pediatric febrile: 1 in 125 visits (0.8%) Pediatric afebrile: 1 in 500 visits (0.2%)

6 Edward P. Sloan, MD, MPH, FACEP 6 Objectives Management Issues Learn likely sz etiologies Seizure Rx without IV access Review seizure termination Rx Explore IV Rx for SE prevention Review EEG in E.D. SE Discuss clinical impact

7 Edward P. Sloan, MD, MPH, FACEP 7 Case Presentations ED Pediatric Seizure Cases Seizing infant, no IV access Pediatric status epilepticus Adolescent sz pt with seizures College student with new onset sz New onset SE in an adolescent Discussion

8 Edward P. Sloan, MD, MPH, FACEP 8 Case #1: Seizing infant, no IV access What therapies can be given? By what route? With what effect?

9 Edward P. Sloan, MD, MPH, FACEP 9 Case #1 Hx 9 month old Febrile illness at home Seizing for paramedics Arrives in arms of CFD No IV access in field

10 Edward P. Sloan, MD, MPH, FACEP 10 Case #1 Px Hyperpyrexia, abn vital signs Actively seizing, generalized Tonic-clonic motor activity Cardiopulm exam OK No IV access available

11 Edward P. Sloan, MD, MPH, FACEP 11 Case #1 Dx What are the diagnoses in this child?

12 Edward P. Sloan, MD, MPH, FACEP 12 Case #1 Dx Generalized convulsive status epilepticus (GCSE) Complex febrile seizure

13 Edward P. Sloan, MD, MPH, FACEP 13 Case #1 Rx: Non-IV Options What treatment would you provide for this patient? A.PR diazepam or rectal gel B.Buccal midazolam C.IM fosphenytoin D.IM midazolam E.IM phenobarbital

14 Edward P. Sloan, MD, MPH, FACEP 14 Case #1 Rx: Non-IV Options IM midazolam Buccal midazolam IM fosphenytoin PR diazepam PR diazepam rectal gel IM phenobarbital less good

15 Edward P. Sloan, MD, MPH, FACEP 15 Case #2: Pediatric SE How do we diagnose ped SE? What is the optimal Rx protocol? Why?

16 Edward P. Sloan, MD, MPH, FACEP 16 Case #2 Hx 7 year old male Seizure-like activity? Patient with staring spells Some headache and shaking movement, esp of hands Frontal headache, vomiting

17 Edward P. Sloan, MD, MPH, FACEP 17 Case #2 Hx (cont) Seen at 2130, 2230 sign-out AMS, r/o seizure disorder Once all of the labs are back, he should be OK to go home…

18 Edward P. Sloan, MD, MPH, FACEP 18 Case #2 Px / Well hydrated CV, lung exams normal Neuro exam intact

19 Edward P. Sloan, MD, MPH, FACEP 19 Case #2 Px (cont) 0220 episode Tachycardia, assoc with AMS Confused, staring off into space Resolved without any Rx Three more episodes over 40 Diaphoresis, urinary incontinence

20 Edward P. Sloan, MD, MPH, FACEP 20 Case #2 Dx What is the likely diagnosis in this pediatric patient? A.Absence status epilepticus B.Complex partial status epilepticus (CPSE) with autonomic signs C.Generalized non-convulsive seizure with autonomic signs D.Generalized convulsive SE

21 Edward P. Sloan, MD, MPH, FACEP 21 Case #2 Dx Repetitive episodes with AMS Associated autonomic signs Rule out generalized nonconvulsive status epilepticus –Complex partial status epilepticus –Absence status epilepticus

22 Edward P. Sloan, MD, MPH, FACEP 22 Case #2 Rx How would you initially treat this pediatric seizure patient? A.IV diazepam B.IV lorazepam C.IV phenobarbital D.IV valproate E.Rectal diazepam

23 Edward P. Sloan, MD, MPH, FACEP 23 Case #2 Rx Would you load this patient with another antiepileptic drug prior to transfer to the childrens hospital? A.Yes B.No

24 Edward P. Sloan, MD, MPH, FACEP 24 Case #2 Rx If you were to load this patient with an AED, what agent would you use? A.IV phenytoin B.IV fosphenytoin C.IV phenobarbital D.IV valproate E.Other

25 Edward P. Sloan, MD, MPH, FACEP 25 Case #2 Rx IV lorazepam IV valproate Transfer to Childrens for ICU observation

26 Edward P. Sloan, MD, MPH, FACEP 26 Case #3: Adolescent Sz Pt with Seizures How to manage seizing children on PO valproate? Does a level need to be checked prior to ED loading? When and how to rapidly restore a therapeutic level?

27 Edward P. Sloan, MD, MPH, FACEP 27 Case #3 Hx 12 yo F Hx autism Hx complex partial seizures Hx secondary generalized tonic- clonic seizures Pt taking Depakote sprinkles BID Presents to ED, has 2 nd seizure

28 Edward P. Sloan, MD, MPH, FACEP 28 Case #3 Px VS OK prior to seizure Chest: Clear CV: Reg without Neuro: Non-focal Generalized tonic-clonic seizure

29 Edward P. Sloan, MD, MPH, FACEP 29 Case #3 Dx Generalized seizures Hx complex partial seizures Sub-therapeutic valproate level vs. break-thru seizure

30 Edward P. Sloan, MD, MPH, FACEP 30 Case #3 Rx After an initial dose of a benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate? A.Yes B.No

31 Edward P. Sloan, MD, MPH, FACEP 31 Case #3 Rx To achieve a high therapeutic level of 125 ucg/ml, if the measured level is 25 ucg/ml, how much IV valproate should be administered in mg/kg ? A.100 mg/kg B. 50 mg/kg C. 20 mg/kg D. 5 mg/kg

32 Edward P. Sloan, MD, MPH, FACEP 32 Case #3 Rx IV lorazepam, avoid status epilepticus Determine valproate level For every mg/kg loaded, the level goes up 5 mcg/ml To increase the level by 100 mcg/ml, give 20 mg/kg. For a 50 kg child, give 1000 mg of IV valproate

33 Edward P. Sloan, MD, MPH, FACEP 33 Case #4: College Student, New Onset Sz What is the likely etiology? What are the long-term implications? How to manage once the seizure has stopped?

34 Edward P. Sloan, MD, MPH, FACEP 34 Case #4 Hx 21 year old college student No known neuro history Final exams, sleepless Great party after the last exam Pt with single generalized seizure in am, upon awakening

35 Edward P. Sloan, MD, MPH, FACEP 35 Case #4 Px Vitals OK Neuro: slightly post-ictal Exam otherwise normal Patient has a 2 nd seizure in the ED

36 Edward P. Sloan, MD, MPH, FACEP 36 Case #4 Dx What is the likley diagnosis in this young adult? A.Complex partial seizures with secondary generalization B.Juvenile myoclonic epilepsy C.Generalized tonic-clonic seizure D.Absence seizure

37 Edward P. Sloan, MD, MPH, FACEP 37 Case #4 Dx Juvenile myoclonic epilepsy Related to sleep deprivation, alcohol consumption, occurs upon awakening May have a history of myoclonic jerks Responds long-term best to valproate

38 Edward P. Sloan, MD, MPH, FACEP 38 Case #4 Rx Benzodiazepines to Rx the acute sz Ongoing protection an issue Phenytoin may not be optimal Valproate may be preferred Avoid status epilepticus

39 Edward P. Sloan, MD, MPH, FACEP 39 Case #5: New Onset AMS/Spells What is the AMS? Is it a seizure? How should we Rx new onset seizure patients? What role does the ED EEG play in sz and SE?

40 Edward P. Sloan, MD, MPH, FACEP 40 Case #5 Hx 13 year old female HA, frontal, cw prior migraines HA relieved with ibuprofen AMS this AM, with ? motor activity Restless at home, thrashing on bed No other systemic sx

41 Edward P. Sloan, MD, MPH, FACEP 41 Case #5 Px Vitals OK, afebrile Alert, O x 3, NAD Head/Neck OK Chest/cor/abd OK Neuro: No focal deficit. MS OK

42 Edward P. Sloan, MD, MPH, FACEP 42 Case #5 Question # 1 What diagnostic tests are indicated at this point?

43 Edward P. Sloan, MD, MPH, FACEP 43 Case #5 Question # 2 Did this patient have a seizure? A.Yes B.No

44 Edward P. Sloan, MD, MPH, FACEP 44 Case #5 Question # 3 Does the patient require admission for observation for possible new onset seizures? A.Yes B.No

45 Edward P. Sloan, MD, MPH, FACEP 45 Case #5 Clinical Course Labs, tox screen neg CT negative Neuro consult: EEG and then D/C Dx: Seizure, migraine HA While EEG applied, pt with AMS Agitation, thrashing on cart

46 Edward P. Sloan, MD, MPH, FACEP 46 Case #5 Question # 4 Is this repeat spell a seizure? What type?

47 Edward P. Sloan, MD, MPH, FACEP 47 Case #5 Question # 5 Does this AMS, motor activity require Rx? What Rx?

48 Edward P. Sloan, MD, MPH, FACEP 48 Case #5 Question # 6 Does the patient require admission for observation for possible new onset seizures?

49 Edward P. Sloan, MD, MPH, FACEP 49 Case #5 Clinical Course (cont) During EEG, pt with R face focal sz Leftward gaze noted Seizure then generalizes Meds are given Seizure is terminated

50 Edward P. Sloan, MD, MPH, FACEP 50 Case #5 Question # 7 What med is to be used for seizure control / SE termination?

51 Edward P. Sloan, MD, MPH, FACEP 51 Case #5 Question # 8 What med is to be used once SE is terminated? Why?

52 Edward P. Sloan, MD, MPH, FACEP 52 Case #5 Question # 9 How should the meds be given? Why?

53 Edward P. Sloan, MD, MPH, FACEP 53 Case #5 Clinical Course (cont) SE terminated with Rx Pt stabilized ALS transfer to Childrens with team Pt with resolving AMS at time of D/C

54 Edward P. Sloan, MD, MPH, FACEP 54 Case #5 Rx Lorazepam to Rx the acute sz IV phenytoin, fosphenytoin, valproate, phenobarbital are AED load options PRN meds during transfer

55 Edward P. Sloan, MD, MPH, FACEP 55 Case #5 Dx What is the diagnosis in this young patient? A.Absence seizure B.Complex partial seizures with secondary generalized seizure C.Focal motor seizure D.Complex migraine headache

56 Edward P. Sloan, MD, MPH, FACEP 56 Case #5 Dx New onset seizure/SE Complex partial seizure with secondary generalized seizure Hx migraine headaches

57 Edward P. Sloan, MD, MPH, FACEP 57 Case #5 Dx Do you believe you could diagnose a seizure on an EEG? A.Yes B.No

58 Edward P. Sloan, MD, MPH, FACEP 58

59 Edward P. Sloan, MD, MPH, FACEP 59

60 Edward P. Sloan, MD, MPH, FACEP 60

61 Edward P. Sloan, MD, MPH, FACEP 61

62 Edward P. Sloan, MD, MPH, FACEP 62

63 Edward P. Sloan, MD, MPH, FACEP 63

64 Edward P. Sloan, MD, MPH, FACEP 64

65 Edward P. Sloan, MD, MPH, FACEP 65 Conclusions Key Learning Points Acute, repetitive spells = sz Multiple meds and routes possible Opportunity to optimize Rx Acute seizure control: IV benzos 2 nd line Rx may differ based on Dx Ongoing needs may influence 2 nd Rx EEG may be of use in ED seizures

66 Edward P. Sloan, MD, MPH, FACEP 66 Recommendations Management Implications Educate about sz etiologies Make multiple drugs available Alternate routes should be used A protocol should exist Utilize EEG when necessary Be aware of optimal Rx at disposition

67 Edward P. Sloan, MD, MPH, FACEP 67 CME Question Have you learned something new about pediatric seizures today such that you can change and improve your clinical practice? A.Yes B.No

68 Edward P. Sloan, MD, MPH, FACEP 68 CME Follow-up CME providers require follow-up to assess if your learning has indeed improved your clinical practice. Can we ask you this question via again in the future? A.Yes B.No

69 Questions?? ferne_aaem_france_2005_sloan_pedssz_fshow.ppt 6/11/ :33 PM Edward P. Sloan, MD, MPH, FACEP Edward P. Sloan, MD, MPH, FACEP Edward P. Sloan, MD, MPH, FACEP


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