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Pediatric Neurologic Emergencies Leybie Ang July 31 2008.

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Presentation on theme: "Pediatric Neurologic Emergencies Leybie Ang July 31 2008."— Presentation transcript:

1 Pediatric Neurologic Emergencies Leybie Ang July 31 2008

2 Objectives Febrile Seizures Status Epilepticus Encephalitis


4 Case Presentation 16 month old, former 38 weeker Previously healthy Brought in by EMS Seizure activity at home Lasting 1-2 minutes Arms and legs twitching 3 days hx of URI symptoms

5 Febrile Seizure – Definition NIH definition  An event in infancy or childhood usually occurring between 3 month and 5 year of age, associated with fever but without evidence of intracranial infection or defined cause of seizure

6 Febrile Seizure - Incidence 2-5% in children < 5yo  Up to 15% Majority between 12-18mo One parent – 4.4x Both parents – 20x Sibling – 3.6 x Second degree relative – 2.7x

7 Simple Febrile Seizure Most common Seizure < 15 minutes No focal features Only once in 24hr time period

8 Complex Febrile Seizure Episodes lasting > 15 minutes Focal features or postical paresis > 1 episode in 24 hrs Seizure in a series with total duration > 30minutes

9 Risk Factors For Recurrence Low fever at time of first sz (<40) Young age (<12 month old) Family hx of febrile sz Short period of time between fever and sz (<24hr) ?male

10 Risk Factors For Developing Epilepsy Family Hx of epilepsy Complex features Presence of early onset neurodevelopmental abnormalies

11 Febrile Seizure - Immunization Risk of febrile seizure increases By 1.5 fold on day of DTP immunization  Risk now reduced if DTaP  Acellular pertussis instead of whole cell pertussis By 3.0 fold with the peak occurring 1-2 weeks after MMR vaccination

12 Differential Diagnosis Shaking/Chills Trauma Toxins Metabolic disorder Meningitis/Encephalitis






18 Febrile Seizure - Management A B C

19 Febrile Seizure - Management Antipyretics Sponging Antiepileptic

20 Febrile Seizures – Antipyretics Uhari et al J peds 1995 126:991 180 kids RDBPC (plac + plac, plac + acet, diaz + acet, diaz + plac) no difference in recurrence x2yrs Schnaiderman et al Eur J Peds 1993 152:747 104 kids RCT acet q4h scheduled or prn, no difference Van Stuijvenberg et al Peds 1998 102:1 230 kids RDBPC ibuprofen to plac no diff X1yr

21 Febrile Seizure - Antipyretics Meremikwa et al Cochrane Database 2002  Systematic review of 12 trials acetaminophen vs placebo +/-sponging Insufficient evidence

22 Febrile Seizure - Diazepam Dose given when:  when child is febrile  before start seizing  or as soon as start seizing Oral dosage given at time of fever – 44% reduction in the risk of febrile seizure per person-year with diazepam

23 Febrile Seizure - Phenobarbital Effective in preventing recurrence of simple febrile seizure Daily therapy reduced the rate of subsequent febrile seizure from 25% to 5% Adverse effect :  hyperactivity, hypersensitivity reaction (SJS), loss of cognitive function

24 Febrile Seizure – Valproic Acid As effective as phenobarbital in preventing recurrent simple febrile seizure More effective than placebo Side effect :  Fatal hepatotoxicity (esp <3yo at greatest risk)

25 Febrile Seizure - Prevention Committee on Quality Improvement Subcommittee on Febrile Seizure of the AAP 1999 “Based on the risk and benefits of effective therapies, neither continuous nor intermittent anticonvulsant therapy is recommended for children with one or more simple febrile seizures. AAP recognises that recurrent episodes of febrile seizures can create anxiety in some parents and their children and as such appropriate educational and emotional support should be provided”

26 Question #1 In the emergency department, you are talking with the parents of a 17 month old boy who was evaluated for a first generalised seizure that lasted 7 minutes and followed by a fever 102.9 F (39.4 C). Other than OM, findings on the physical examination were normal, and the child was discharged home. The child is developmentally normal. Upon examination, the child now appears well.

27 Of the following, your MOST likely statement to the parents is that A. antipyretic agents are effective in preventing future febrile seizures B. CT head is preferred to MRI brain for evaluation of this child C. EEG is not indicated D. The chance of another febrile sz is ~50% E. The child has a 5% chance of developing epilepsy


29 Status Epilepticus - Introduction EFA  Two or more sequential seizures without full recovery of consciousness between seizures, or more than 30 minutes of continuous seizure activity 10-58 per 100,000 per year for children 1 to 19 year old More common in in children with epilepsy 9-27%

30 Status Epilepticus - Etiology 26% acute CNS insult  Bleed  Trauma  Infection 20% underlying seizure disorder  Sudden discontinuation of meds  Drug interaction  Fever 53% unknown

31 Status Epilepticus

32 Status Epilepticus – Blood Culture Should blood culture be routinely done in children in SE? Six Class III studies, total 357 children, BC positive in 2.5% Insufficient data to support or refute in children whether blood cultures should be done routine basis in children whom there is no clinical suspicious for infection

33 Status Epilepticus – Lumbar Puncture Should LP be routinely done in children with SE? Class III studies – out of 1,859 children 12.8% has documented CNS infection Insufficient data to support or refute in children whether lumbar puncture should be done routine basis in children whom there is no clinical suspicious for infection

34 Status Epilepticus – AED Levels Should AED levels be routinely obtained in children taking AED who develop SE? Class II data showed that low AED levels in 32% of children on AEDs AED levels should be considered when a child with epilepsy on AED prophylaxis develops SE

35 Status Epilepticus – Toxicology Testing Should toxicology testing be routinely ordered in children with SE? Class III studies showed that a diagnosis of ingestion in 3.6% Toxicology testing maybe considered in children with SE, when no apparent etiology is immediately identified. Specific serum toxicology level is required

36 Status Epilepticus - EEG Should an EEG be routinely performed in the evaluation of a child with SE? Class III studies reported that abnormal brain activity on 43.1% of EEG done on SE EEG may be considered in a child with new onset SE

37 Status Epilepticus – Imaging Neuroimaging may be considered for the evaluation of the child with SE if there are clinical indications or if the etiology is appropriately stabilised and the seizure activity controlled

38 Imaging - CT vs. MRI MRI useful for:  More detailed view of brain anatomy  Better screen for CNS malformations and dysplastic lesions, temporal lobe (esp. hippocampus) CT useful for:  Larger neoplasms, old infarctions, major malformative processes  Assessment of the critically ill child

39 Status Epilepticus - Managemnet A B C

40 SE treatment 1 st line anticonvulsants  IV Lorazepam 0.1mg/kg Diazepam 0.2 mg/kg Midazolam 0.2 mg/kg  Rectal diazepam 2-5 yrs – 0.5 mg/kg 6-11 yrs – 0.3 mg/kg >12 yrs – 0.2 mg/kg  IM, intranasal, buccal midazolam

41 SE treatment 2 nd line agents  Phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min)  Fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min) 3 rd line agents  Phenobarbital 20mg/kg @ 100mg/min  Repeat prn 5-10mg/kg  Maximum 40 mg/kg or 1 gram

42 Refractory SE treatment Consider midazolam  0.2 mg/kg bolus  1-10 mcg/kg/min infusion Induce barbiturate coma  Pentobarbital 5-15 mg/kg @ 25 mg/min  Then 1-5 mg/kg/hour Others  Valproic acid  Paraldehyde, chloral hydrate  Propofol, inhalational anesthesia, paralysis  lidocaine

43 Status Epilepticus - Complications Hypoxia  Impaired ventilation  Increased secretions  Increased O2 consumption  Impaired O2 delivery  Metabolic and respiratory acidosis Brain injury  Hypoxia and hypoperfusion  MR, behaviour changes, neuro deficits

44 Status Epilepticus - Complications Morbidity < 1yo - 30% > 3yo – 6% Mortality  3%

45 Question #2 A 8 month old girl is brought into the emergency department in status epilepticus. She has had diarrhea for the past 4 days. The infant had received bottled water for the past 3 days of her illness and cola for the past 24hr.

46 Of the following, the MOST likely cause of her status epilepticus is A. Hypocalcemia B. Hypoglycemia C. Hypokalemia D. Hypomagnesemia E. Hyponatremia


48 Case Presentation 16 yo old female presents with fever, headache, neck stiffness, swallowing difficulties and altered mental status Symptoms have worsened over past 2 days. Roommate noted a change in behaviour for the past week 2 weeks ago had a bad URTI- missed 2 days of school

49 Encephalitis Defined as acute CNS dysfunction with radiographic or laboratory evidence of brain inflammation 1. Primary Encephalitis  cause bloodstream infection, then enter the CNS 2. Post- or Parainfectious  not caused by direct CNS infection  consequence of the host’s immune response

50 Encephalitis HSV - typically infects neurons in the temporal lobe Rabies - predominantly affects the pons, medulla, cerebellum, and hippocampus Japanese encephalitis virus affects the brainstem and basal ganglia.

51 Post- Parainfectious Encephalitis occurs days to weeks after the onset of an infection hypothesized to be caused by an aberrant immune response against brain antigens such as myelin basic protein Subsequent demyelination causes focal or global CNS dysfunction

52 Encephalitis - Epidemiology overall incidence of hospitalization was 7.3 cases/100,000 annually Children < 1 yo - 13.7 cases/100,000 per yr Adults >65 yo - 10.6 cases/100,000 per yr


54 Clinical presentation Fever Headache Altered mental status Focal neurologic signs spectrum of clinical evolution during encephalitis varies widely



57 Encephalitis CT scan – nml at the onset of encephalitis. MRI – much more sensitive for acute changes EEG - helpful adjunct +/- localize the region of encephalitic involvement  considerably more sensitive

58 Management Appropriate antiviral, antimicrobial or antifungal therapies Intravenous immune globulin, corticosteroids, or other immune system modulators.

59 Herpes Simplex Virus Encephalitis Most common encephalitis diagnosed Fever Personality change Autonomic dysfunction Dysphagia Seizures Headache Altered level of consciousness

60 HSV Mildly elevated CSF WBC counts (lymphocyte predominant) and CSF protein CT and MRI studies - normal if obtained early in the course of illness  Unilateral or bilateral temporal lobe involvement (most common finding) Diagnostic test - HSV DNA detection by PCR on the CSF  both highly sensitive and specific  If initial result negative, test should be repeated on a second CSF specimen.

61 Treatment IV acyclovir 10 mg/kg per dose every 8 hours for 2 to 3 weeks. Better outcomes if:  age < 30 yo  shorter duration of symptoms before initiation of treatment  GCS >10 at the time of presentation.

62 Investigations CT head LP CBC, Blood culture Lytes Glucose ESR, CRP

63 Back to our patient

64 Question #3 For a patient who is suspected of having acute encephalitis, which of the following studies is most likely tobe helpful? A. Cerebrospinal fluid glucose level. B. Computed tomography scan. C. Electroencephalography. D. Magnetic resonance imaging. E. Viral culture

65 Any Questions?

66 References C Waruiru and R Appleton Febrile seizures: an update Arch Dis Child. 2004 August; 89(8): 751–756. Jones T. Jacobsen SJ. Childhood febrile seizures: overview and implications International Journal of Medical Sciences. 4(2):110-4, 2007. Baumann RJ. Duffner PK. Treatment of children with simple febrile seizures: the AAP practice parameter. American Academy of Pediatrics. Pediatric Neurology. 23(1):11-7, 2000 Jul. AAP Practice Parameter: Long Term Treatment of the Child With Simple Febrile Seizure Pediatrics. 103(6) June 1999

67 References Appleton R. Choonara I. Martland T. Phillips B. Scott R. Whitehouse W. The treatment of convulsive status epilepticus in children. Archives of Disease in Childhood. 83(5):415-9, 2000 Nov. Riviello JJ Jr. Ashwal S. Hirtz D. Glauser T. Ballaban-Gil K. Kelley K. Morton LD. Phillips S. Sloan E. Shinnar S. American Academy of Neurology Subcommittee. Practice Committee of the Child Neurology Society. Practice parameter: diagnostic assessment of the child with status epilepticus Neurology. 67(9):1542-50, 2006 Nov 14.

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