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1 Pediatric Seizure and Status Epilepticus Management in the Emergency Setting
2 University of Illinois College of Medicine Chicago, IL Edward P. Sloan, MD, MPH Associate Professor & Research Development Director Dept of Emergency MedicineUniversity of Illinois College of MedicineChicago, IL
3 Attending Physician Emergency Medicine University of Illinois HospitalOur Lady of the ResurrectionMedical Center
4 Pediatric Seizures & SE Clinical Case A 13 year old female presents with a frontal HA and prior migraines that are relieved with ibuprofenShe had some AMS in the AM, with unusual motor activity (restless, thrashing on bed)She had no other systemic sx, recent illness, or head traumaShe presented with normal vital signs and normal neurologic examWhat should the emergency physician do?What is the expected outcome of this patient?
5 Overview Global Objectives Learn more about pediatric seizuresFocus on peds sz etiologiesIncrease awareness of Rx optionsEnhance our ED managementImprove patient care & outcomesMaximize MD & patient satisfaction
6 Overview Session Objectives Review main peds sz types, etiologiesBriefly discuss Rx based on sz typeDiscuss relevant ED peds sz casesSummarize what Rx options existDiscuss rational treatment decisions
7 Overview Pediatric Sz Epidemiology Common EMS & ED problemSzs are up to 6% of EMS encountersUp to 1% of all ED visits are peds szPeds febrile: 1 in 125 visits (0.8%)Peds afebrile: 1 in 500 visits (0.2%)
8 Overview Pediatric Sz Epidemiology 2-5% have a febrile seizure1% have an afebrile sz by age 14Highest afebrile sz rate before age 3% of children dvlp epilepsySE most common before age 1
9 Overview Pediatric SE Epidemiology Mean age 3.2 yrs, median age 1 year61% by age 3Etiology age dependent25% is febrile SEBefore age 1, 75% due to acute insultEpilepsy, fever, CNS infection common
10 Pediatric Sz Etiologies Meningitis Altered mental status universalSeizures in 23% of meningitis casesComplex & GTC seizures commonSimple seizures rarely seenHIB vaccine makes this etiology rare
11 Pediatric Sz Etiologies Hyponatremia Causes long duration szs and SEInfants < 6 months old, no clear etiolToo much water in formulaHypothermia (Temp < 36.5 degrees)
12 Pediatric Sz Etiologies Cocaine Toxicity Consider in new onset seizuresCrack cocaine rocks ingestedEspecially when no other etiologyCommon in urban EDs
13 Pediatric Seizures Seizure Outcome Immature CNS, myelinizationMore prone to seizuresMore resistant to consequencesContinuous seizures less toxicSE carries a low mortality (3-6%)
14 Pediatric Seizures SE Outcome Based on CNS status prior to SENormal CNS, 64% remain intactMortality related to two factors:Acute neurologic insultChronic CNS condition
15 Pediatric Seizures Seizure Type Classification GeneralizedInvolves both cerebral hemispheresConvulsive: tonic-clonic seizuresNon-convulsive: absence seizuresPartialInvolves one cerebral hemisphereSimple: no impaired consciousnessComplex: impaired consciousness
17 Seizure Classification Partial Seizures Simple seizures (no LOC)Focal motor (Jacksonian)Sensory or somatosensoryAutonomicPsychicComplex (impaired consciousness)Involves some cognitive, affective sxTemporal lobe, psychomotor seizures
18 Pediatric Seizures Other Generalized Sz Types Neonatal seizuresBenign childhood epilepsy (Rolandic)Infantile spasms (West syndrome)Lennox-Gastaut syndromeAtonic seizuresFebrile seizures
19 Pediatric Seizures Status Epilepticus Types Convulsive SE : tonic-clonic szNon-convulsive SE: no tonic-clonic szAbsence SEComplex partial SESubtle SE: prolonged convulsive SEWorst prognosis, mortality > 30%Persistent coma, focal motor mvmts only
20 Specific Seizure Types Generalized Tonic-Clonic Sz Seizure described as a convulsionMay occur primarily or secondarilyMay be preceded by prodrome or auraTonic, then clonic phaseTongue biting, urinary incontinenceLast for minutes, then post-ictal
21 Specific Seizure Types Absence Seizure Petit mal epilepsyBrief, limited motor activitySudden interruption of consciousnessSlight clonic mvmts, myoclonic jerksAutomatisms also can be seenLast about 10 sec, not post-ictal
22 Specific Seizure Types Partial Seizure Focal motor sz (Jacksonian, frontal)Focus and/or lesion in cerebrumSz clearly related to a lesionSz type related to site of sz focusCT scan is usefulSimple partial sz pts have no AMS
23 Specific Seizure Types Complex Partial Seizure Psychomotor, temporal lobe epilepsyOften a history of febrile seizuresComplex aura, altered behaviorAutomatisms: lip smacking, chewingNot complete LOC, instead confusedMay secondarily generalize
24 Specific Seizure Types Neonatal Seizure Occur in first 28 days of lifeMost occur shortly after birthSubtle sz: lip smack, eye mvmt, apneaPerinatal asphyxia, metabolic abnHypoglycemia, hypocalcemiaCNS infection, hemorrhage, lesion
25 Specific Seizure Types Benign Childhood Epilepsy Rolandic epilepsyOnset between 3 and 13 years of ageOften occurs upon awakeningFacial mvmts, grimacing, vocalizationsEEG diagnosis
26 Specific Seizure Types Infantile Spasms West syndromeOccurs up to one yearMay be symptomatic or idiopathicSudden tonic movements of the head, trunk, extremitiesMust do full work-up, incl metabolicCaution, AED hepatotoxicity a risk
27 Specific Seizure Types Lennox-Gastaut Syndrome Onset from 1-8 yearsPeaks at 3-5 yearsMultiple seizure typesGTC, tonic, absence, atonic szsED Hx: exac of known sz disorder
28 Specific Seizure Types Atonic Seizures Astatic or akinetic seizuresSudden loss of motor toneChild falls to the floorMay have myoclonic jerksNo clear generalized seizureNo etiology of apparent syncopal episode
29 Specific Seizure Types Febrile Seizures Age: 6 months to 5 yearsRelated to rapid rise in temperatureBrief, self-limited generalized szComplex: Focal, > min, flurry25% recurrence, esp if in child < 1 yr oldRisk of epilepsy not significantly greater
30 Specific Seizure Types Juvenile Myoclonic Epilepsy Common in teens, young adultsEtiology of generalized TC seizuresHistory of staring spellsHistory of AM clumsiness, myoclonusSleep deprivation, EtOH precipitantsPhenytoin: worse myoclonus, absence sz
31 Specific SE Types Generalized Convulsive SE Seizure lasting greater than 5-10 minRefractory to initial benzo therapyFlurry of seizures and comaCNS injury likely after minutesGlutamate, cell death, tissue necrosisInjury even if systemic sx controlled
32 Specific SE Types Non-convulsive SE No generalized tonic-clonic szAbsence SEComplex partial SENo frank comaMore common in childrenNot always due to co-morbidityMortality ?? not as high as in GCSE
33 Specific SE Types Subtle SE Late manifestation of GCSE, frank comaNo longer with tonic-clonic mvmtsStill actively seizing (electrical SE)Usu in older patientsMarked co-morbidity (encephalopathic)Highest SE mortality
34 Seizure Therapy Generalized Seizure Protocol BenzodiazepinesPR diazepam, IM midazolam, IV lorazepamPhenytoinsFosphenytoin can be given IV or IMPhenobarbital or valproateLess sedation with valproatePropofol or midazolam infusionsEEG monitoring, BP support key
36 Case Presentations ED Pediatric Seizure Cases Pediatric complex partial SENew onset SE in an adolescentNew onset sz in a college student
37 Pediatric SE: Pediatric Complex Partial SE How do we Dx complex partial SE?What is the optimal Rx protocol?Why?
38 Pediatric SE Hx 7 year old male Seizure-like activity? Patient with staring spellsSome headache and shaking movement, esp of handsFrontal headache, vomiting
39 Pediatric SE 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…”
40 Pediatric SE Px 98.7 98/60 72 20 Well hydrated CV, lung exams normal /Well hydratedCV, lung exams normalNeuro exam intact
41 Pediatric SE Clinical Course 0220 “episode”Tachycardia, BP OK, airway OKConfused, staring off into spaceEpisode lasted < 5 minutesResolved without any Rx
42 Pediatric SE Clinical Course (con’t) Three more episodes over 40’Similar autonomic symptomsSome non-purposeful ext mvmtsDiaphoresis, urinary incontinenceRemained somnolent between episodes
43 Pediatric SE Dx Repetitive episodes with AMS Autonomic symptoms noted Non-purposeful mvmts notedRule out complex partial status epilepticus (CPSE)
44 Pediatric SE Rx IV lorazepam IV valproate Transfer to Children’s ICU observationUncomplicated course
45 Adolescent SE: New Onset AMS/Spells What is the AMS?Is it a seizure?How should we Rx new onset szs?What is the role of the ED EEG?When should it be ordered?
46 Adolescent SE Hx 13 year old female Frontal HA and prior migraines HA relieved with ibuprofenAMS in AM, with ?? motor activityRestless at home, thrashing on bedNo other systemic sx or recent illness
47 Adolescent SE Px Vitals OK, afebrile Alert, O x 3, NAD Head/Neck OK Chest/cor/abd OKNeuro: No focal deficit. MS OK
48 Adolescent SE Question # 1 What diagnostic tests are indicated at this point?
49 Adolescent SE Question # 2 Did the patient have a seizure?Does it influence Dx, Rx?
50 Adolescent SE Question # 3 Does the patient require admission for observation for possible new onset seizures?
51 Adolescent SE Clinical Course Labs, tox screen negCT negativeNeuro consult: EEG and then D/CDx: AMS, r/o Seizure; migraine HAWhile EEG applied, pt with AMSAgitation, thrashing on cart
52 Adolescent SE Question # 4 Is this repeat spell a seizure?What type?
53 Adolescent SE Question # 5 Does this AMS and motor activity require Rx?What Rx?
54 Adolescent SE Question # 6 Does the patient now require admission for observation for possible new onset seizures?
55 Adolescent SE Clinical Course (con’t) During EEG, pt with R face focal szLeftward gaze notedSeizure then generalizedMeds were givenSeizure terminated
56 Adolescent SE Question # 7 What med is to be used for seizure control / SE termination?
57 Adolescent SE Question # 8 What med is to be used once SE is terminated?Why?
58 Adolescent SE Question # 9 How should the meds be given?Why?
59 Adolescent SE Clinical Course (con’t) SE terminated with RxPt stabilized, still somnulentALS transfer team to Children’sPt with resolving AMS at time of D/C
60 Adolescent SE Dx New onset SE Complex partial seizures with generalized seizure / SEHx migraine headaches
61 Adolescent SE Rx Lorazepam to Rx the acute sz 2mg IVP x 2Valproate for ongoing protection25 mg/kg load administeredInfused over 20 minutesPRN meds during transfer
66 Juvenile Myoclonic Sz: College Student, New Onset Sz What is the likely etiology?What is JME?What are the long-term implications?How to RX once the sz terminated?
67 Juvenile Myoclonic Sz Hx 21 year old college studentNo prior neuro historyFinal exams, sleeplessGreat party after the last examPt with single generalized szSeizure upon awakening
68 Juvenile Myoclonic Sz Px Vitals OKNeuro: slightly post-ictalExam otherwise normalPatient has a 2nd seizure in the ED
69 Juvenile Myoclonic Sz Dx Juvenile myoclonic epilepsyRelated to sleep deprivation, alcohol consumptionOccurs upon awakeningResponds best to valproatePhenytoin may exacerbate sx
70 Juvenile Myoclonic Sz Rx Benzodiazepines to Rx the acute szOngoing protection an issueValproate is likely the drug of choicePhenytoin may not be optimalAvoid status epilepticus
71 Conclusions Clinical Pearls Acute, repetitive spells = szOngoing altered mental status = complex partial SETreat acute szs with lorazepamValproate is the etiology-specific ongoing Rx in many young peopleKnow the specific JME clinical setting
72 Recommendations 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