Presentation on theme: "Pediatric Seizure and SE Patient ED Care: Challenging Cases"— Presentation transcript:
1Pediatric Seizure and SE Patient ED Care: Challenging Cases Edward P. Sloan, MD, MPH, FACEP1
2Dept of Emergency Medicine University of Illinois College of Medicine Edward P. Sloan, MD, MPHProfessorDept of Emergency Medicine University of Illinois College of MedicineChicago, ILEdward P. Sloan, MD, MPH, FACEP2
3Attending Physician Emergency Medicine University of Illinois HospitalOur Lady of the Resurrection HospitalChicago, ILEdward P. Sloan, MD, MPH, FACEP3
4Housekeeping Issues Disclosures Meeting support from UCB Pharma Thank you Dave RiccioIV levetiracetam, a second generation AEDMay soon be an IV parenteral option in the EDPlease fill out a CME form with yourPlease give feedback to improve our work
5Overview Acute Pediatric Seizures Common ED problemSeizures: 6% of EMS encountersPediatric seizures: 1% of all ED visitsPediatric febrile: 1 in 125 visits (0.8%)Pediatric afebrile: 1 in 500 visits (0.2%)
6Objectives Management Issues Learn likely sz etiologiesSeizure Rx without IV accessReview seizure termination RxExplore IV Rx for SE preventionReview EEG in E.D. SEDiscuss clinical impact
7Case Presentations ED Pediatric Seizure Cases Seizing infant, no IV accessPediatric status epilepticusAdolescent sz pt with seizuresCollege student with new onset szNew onset SE in an adolescentDiscussion
8Case #1: Seizing infant, no IV access What therapies can be given?By what route?With what effect?
9Febrile illness at home Seizing for paramedics Arrives in arms of CFD Case #1 Hx9 month oldFebrile illness at homeSeizing for paramedicsArrives in arms of CFDNo IV access in field
10Hyperpyrexia, abn vital signs Actively seizing, generalized Case #1 PxHyperpyrexia, abn vital signsActively seizing, generalizedTonic-clonic motor activityCardiopulm exam OKNo IV access available
11What are the diagnoses in this child? Case #1 DxWhat are the diagnoses in this child?
12Generalized convulsive status epilepticus (GCSE) Case #1 DxGeneralized convulsive status epilepticus (GCSE)Complex febrile seizure
13Case #1 Rx: Non-IV Options What treatment would you provide for this patient?PR diazepam or rectal gelBuccal midazolamIM fosphenytoinIM midazolamIM phenobarbital
14Case #1 Rx: Non-IV Options IM midazolamBuccal midazolamIM fosphenytoinPR diazepamPR diazepam rectal gelIM phenobarbital less good
15How do we diagnose ped SE? What is the optimal Rx protocol? Why? Case #2: Pediatric SEHow do we diagnose ped SE?What is the optimal Rx protocol?Why?
16Seizure-like activity? Patient with staring spells Case #2 Hx7 year old maleSeizure-like activity?Patient with staring spellsSome headache and shaking movement, esp of handsFrontal headache, vomiting
17AMS, r/o seizure disorder Case #2 Hx (con’t)Seen at 2130, 2230 sign-outAMS, r/o seizure disorder“Once all of the labs are back, he should be OK to go home…”
1898.7 98/60 72 20 Well hydrated CV, lung exams normal Neuro exam intact Case #2 Px/Well hydratedCV, lung exams normalNeuro exam intact
19Tachycardia, assoc with AMS Confused, staring off into space Case #2 Px (con’t)0220 “episode”Tachycardia, assoc with AMSConfused, staring off into spaceResolved without any RxThree more episodes over 40’Diaphoresis, urinary incontinence
20What is the likely diagnosis in this pediatric patient? Case #2 DxWhat is the likely diagnosis in this pediatric patient?Absence status epilepticusComplex partial status epilepticus (CPSE) with autonomic signsGeneralized non-convulsive seizure with autonomic signsGeneralized convulsive SE
21Repetitive episodes with AMS Associated autonomic signs Case #2 DxRepetitive episodes with AMSAssociated autonomic signsRule out generalized nonconvulsive status epilepticusComplex partial status epilepticusAbsence status epilepticus
22How would you initially treat this pediatric seizure patient? Case #2 RxHow would you initially treat this pediatric seizure patient?IV diazepamIV lorazepamIV phenobarbitalIV valproateRectal diazepam
23Case #2 RxWould you load this patient with another antiepileptic drug prior to transfer to the children’s hospital?YesNo
24Case #2 RxIf you were to load this patient with an AED, what agent would you use?IV phenytoinIV fosphenytoinIV phenobarbitalIV valproateOther
25Transfer to Children’s for ICU observation Case #2 RxIV lorazepamIV valproateTransfer to Children’s for ICU observation
26Case #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?
27Hx complex partial seizures Case #3 Hx12 yo FHx autismHx complex partial seizuresHx secondary generalized tonic-clonic seizuresPt taking Depakote sprinkles BIDPresents to ED, has 2nd seizure
28Generalized tonic-clonic seizure Case #3 PxVS OK prior to seizureChest: ClearCV: Reg withoutNeuro: Non-focalGeneralized tonic-clonic seizure
29Hx complex partial seizures Case #3 DxGeneralized seizuresHx complex partial seizuresSub-therapeutic valproate level vs. break-thru seizure
30Case #3 RxAfter an initial dose of a benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate?YesNo
31Case #3 RxTo 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 ?100 mg/kg50 mg/kg20 mg/kg5 mg/kg
32IV lorazepam, avoid status epilepticus Determine valproate level Case #3 RxIV lorazepam, avoid status epilepticusDetermine valproate levelFor every mg/kg loaded, the level goes up 5 mcg/mlTo increase the level by 100 mcg/ml, give 20 mg/kg. For a 50 kg child, give 1000 mg of IV valproate
33Case #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?
3421 year old college student No known neuro history Case #4 Hx21 year old college studentNo known neuro historyFinal exams, sleeplessGreat party after the last examPt with single generalized seizure in am, upon awakening
35Neuro: slightly post-ictal Exam otherwise normal Case #4 PxVitals OKNeuro: slightly post-ictalExam otherwise normalPatient has a 2nd seizure in the ED
36What is the likley diagnosis in this young adult? Case #4 DxWhat is the likley diagnosis in this young adult?Complex partial seizures with secondary generalizationJuvenile myoclonic epilepsyGeneralized tonic-clonic seizureAbsence seizure
37Juvenile myoclonic epilepsy Case #4 DxJuvenile myoclonic epilepsyRelated to sleep deprivation, alcohol consumption, occurs upon awakeningMay have a history of myoclonic jerksResponds long-term best to valproate
38Benzodiazepines to Rx the acute sz Ongoing protection an issue Case #4 RxBenzodiazepines to Rx the acute szOngoing protection an issuePhenytoin may not be optimalValproate may be preferredAvoid status epilepticus
39Case #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?
40HA, frontal, cw prior migraines HA relieved with ibuprofen Case #5 Hx13 year old femaleHA, frontal, cw prior migrainesHA relieved with ibuprofenAMS this AM, with ? motor activityRestless at home, thrashing on bedNo other systemic sx
41Neuro: No focal deficit. MS OK Case #5 PxVitals OK, afebrileAlert, O x 3, NADHead/Neck OKChest/cor/abd OKNeuro: No focal deficit. MS OK
42What diagnostic tests are indicated at this point? Case #5 Question # 1What diagnostic tests are indicated at this point?
43Did this patient have a seizure? Yes No Case #5 Question # 2Did this patient have a seizure?YesNo
44Case #5 Question # 3Does the patient require admission for observation for possible new onset seizures?YesNo
45Neuro consult: EEG and then D/C Dx: Seizure, migraine HA Case #5 Clinical CourseLabs, tox screen negCT negativeNeuro consult: EEG and then D/CDx: Seizure, migraine HAWhile EEG applied, pt with AMSAgitation, thrashing on cart
46Is this repeat spell a seizure? What type? Case #5 Question # 4Is this repeat spell a seizure?What type?
47Does this AMS, motor activity require Rx? What Rx? Case #5 Question # 5Does this AMS, motor activity require Rx?What Rx?
48Case #5 Question # 6Does the patient require admission for observation for possible new onset seizures?
49Case #5 Clinical Course (con’t) During EEG, pt with R face focal szLeftward gaze notedSeizure then generalizesMeds are givenSeizure is terminated
50What med is to be used for seizure control / SE termination? Case #5 Question # 7What med is to be used for seizure control / SE termination?
51What med is to be used once SE is terminated? Why? Case #5 Question # 8What med is to be used once SE is terminated?Why?
52How should the meds be given? Why? Case #5 Question # 9How should the meds be given?Why?
53Case #5 Clinical Course (con’t) SE terminated with RxPt stabilizedALS transfer to Children’s with teamPt with resolving AMS at time of D/C
54Lorazepam to Rx the acute sz Case #5 RxLorazepam to Rx the acute szIV phenytoin, fosphenytoin, valproate, phenobarbital are AED load optionsPRN meds during transfer
55What is the diagnosis in this young patient? Absence seizure Case #5 DxWhat is the diagnosis in this young patient?Absence seizureComplex partial seizures with secondary generalized seizureFocal motor seizureComplex migraine headache
56Complex partial seizure with secondary generalized seizure Case #5 DxNew onset seizure/SEComplex partial seizure with secondary generalized seizureHx migraine headaches
57Do you believe you could diagnose a seizure on an EEG? Yes No Case #5 DxDo you believe you could diagnose a seizure on an EEG?YesNo
65Conclusions Key Learning Points Acute, repetitive spells = szMultiple meds and routes possibleOpportunity to optimize RxAcute seizure control: IV benzos2nd line Rx may differ based on DxOngoing needs may influence 2nd RxEEG may be of use in ED seizures
66Recommendations Management Implications Educate about sz etiologiesMake multiple drugs availableAlternate routes should be usedA protocol should existUtilize EEG when necessaryBe aware of optimal Rx at disposition
67CME QuestionHave you learned something new about pediatric seizures today such that you can change and improve your clinical practice?YesNo
68CME Follow-upCME 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?YesNo
69Questions??Edward P. Sloan, MD, MPH, FACEPferne_aaem_france_2005_sloan_pedssz_fshow.ppt4/1/2017 4:49 PMEdward P. Sloan, MD, MPH, FACEP54154