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

2. Dept of Emergency Medicine University of Illinois College of Medicine
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. 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
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Please give feedback to improve our work

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. 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. 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. Case #1: Seizing infant, no IV access
What therapies can be given?
By what route?
With what effect?

9. Febrile illness at home Seizing for paramedics Arrives in arms of CFD
Case #1 Hx
9 month old
Febrile illness at home
Seizing for paramedics
Arrives in arms of CFD
No IV access in field

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

11. What are the diagnoses in this child?
Case #1 Dx
What are the diagnoses in this child?

12. Generalized convulsive status epilepticus (GCSE)
Case #1 Dx
Generalized convulsive status epilepticus (GCSE)
Complex febrile seizure

13. Case #1 Rx: Non-IV Options
What treatment would you provide for this patient?
PR diazepam or rectal gel
Buccal midazolam
IM fosphenytoin
IM midazolam
IM phenobarbital

14. Case #1 Rx: Non-IV Options
IM midazolam
Buccal midazolam
IM fosphenytoin
PR diazepam
PR diazepam rectal gel
IM phenobarbital less good

15. How do we diagnose ped SE? What is the optimal Rx protocol? Why?
Case #2: Pediatric SE
How do we diagnose ped SE?
What is the optimal Rx protocol?
Why?

16. Seizure-like activity? Patient with staring spells
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. AMS, r/o seizure disorder
Case #2 Hx (con’t)
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. 98.7 98/60 72 20 Well hydrated CV, lung exams normal Neuro exam intact
Case #2 Px /
Well hydrated
CV, lung exams normal
Neuro exam intact

19. Tachycardia, assoc with AMS Confused, staring off into space
Case #2 Px (con’t)
0220 “episode”
Tachycardia, assoc with AMS
Confused, staring off into space
Resolved without any Rx
Three more episodes over 40’
Diaphoresis, urinary incontinence

20. What is the likely diagnosis in this pediatric patient?
Case #2 Dx
What is the likely diagnosis in this pediatric patient?
Absence status epilepticus
Complex partial status epilepticus (CPSE) with autonomic signs
Generalized non-convulsive seizure with autonomic signs
Generalized convulsive SE

21. Repetitive episodes with AMS Associated autonomic signs
Case #2 Dx
Repetitive episodes with AMS
Associated autonomic signs
Rule out generalized nonconvulsive status epilepticus
Complex partial status epilepticus
Absence status epilepticus

22. How would you initially treat this pediatric seizure patient?
Case #2 Rx
How would you initially treat this pediatric seizure patient?
IV diazepam
IV lorazepam
IV phenobarbital
IV valproate
Rectal diazepam

23. Case #2 Rx
Would you load this patient with another antiepileptic drug prior to transfer to the children’s hospital?
Yes No

24. Case #2 Rx
If you were to load this patient with an AED, what agent would you use?
IV phenytoin
IV fosphenytoin
IV phenobarbital
IV valproate
Other

25. Transfer to Children’s for ICU observation
Case #2 Rx
IV lorazepam
IV valproate
Transfer to Children’s for ICU observation

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. Hx complex partial seizures
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 2nd seizure

28. Generalized tonic-clonic seizure
Case #3 Px
VS OK prior to seizure
Chest: Clear
CV: Reg without
Neuro: Non-focal
Generalized tonic-clonic seizure

29. Hx complex partial seizures
Case #3 Dx
Generalized seizures
Hx complex partial seizures
Sub-therapeutic valproate level vs. break-thru seizure

30. Case #3 Rx
After an initial dose of a benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate?
Yes No

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 ?
100 mg/kg
50 mg/kg
20 mg/kg
5 mg/kg

32. IV lorazepam, avoid status epilepticus Determine valproate level
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. 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. 21 year old college student No known neuro history
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. Neuro: slightly post-ictal Exam otherwise normal
Case #4 Px
Vitals OK
Neuro: slightly post-ictal
Exam otherwise normal
Patient has a 2nd seizure in the ED

36. What is the likley diagnosis in this young adult?
Case #4 Dx
What is the likley diagnosis in this young adult?
Complex partial seizures with secondary generalization
Juvenile myoclonic epilepsy
Generalized tonic-clonic seizure
Absence seizure

37. Juvenile myoclonic epilepsy
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. Benzodiazepines to Rx the acute sz Ongoing protection an issue
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. 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. HA, frontal, cw prior migraines HA relieved with ibuprofen
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. Neuro: No focal deficit. MS OK
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. What diagnostic tests are indicated at this point?
Case #5 Question # 1
What diagnostic tests are indicated at this point?

43. Did this patient have a seizure? Yes No
Case #5 Question # 2
Did this patient have a seizure?
Yes No

44. Case #5 Question # 3
Does the patient require admission for observation for possible new onset seizures?
Yes No

45. Neuro consult: EEG and then D/C Dx: Seizure, migraine HA
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. Is this repeat spell a seizure? What type?
Case #5 Question # 4
Is this repeat spell a seizure?
What type?

47. Does this AMS, motor activity require Rx? What Rx?
Case #5 Question # 5
Does this AMS, motor activity require Rx?
What Rx?

48. Case #5 Question # 6
Does the patient require admission for observation for possible new onset seizures?

49. Case #5 Clinical Course (con’t)
During EEG, pt with R face focal sz
Leftward gaze noted
Seizure then generalizes
Meds are given
Seizure is terminated

50. What med is to be used for seizure control / SE termination?
Case #5 Question # 7
What med is to be used for seizure control / SE termination?

51. What med is to be used once SE is terminated? Why?
Case #5 Question # 8
What med is to be used once SE is terminated?
Why?

52. How should the meds be given? Why?
Case #5 Question # 9
How should the meds be given?
Why?

53. Case #5 Clinical Course (con’t)
SE terminated with Rx
Pt stabilized
ALS transfer to Children’s with team
Pt with resolving AMS at time of D/C

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

55. What is the diagnosis in this young patient? Absence seizure
Case #5 Dx
What is the diagnosis in this young patient?
Absence seizure
Complex partial seizures with secondary generalized seizure
Focal motor seizure
Complex migraine headache

56. Complex partial seizure with secondary generalized seizure
Case #5 Dx
New onset seizure/SE
Complex partial seizure with secondary generalized seizure
Hx migraine headaches

57. Do you believe you could diagnose a seizure on an EEG? Yes No
Case #5 Dx
Do you believe you could diagnose a seizure on an EEG?
Yes No

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

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. CME Question
Have you learned something new about pediatric seizures today such that you can change and improve your clinical practice?
Yes No

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?
Yes No

69. Questions??
Edward P. Sloan, MD, MPH, FACEP
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