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 Medicine
University of Illinois College of Medicine
Chicago, IL

3. Attending Physician Emergency Medicine
University of Illinois Hospital
Our Lady of the Resurrection
Medical Center

4. Pediatric Seizures & SE Clinical Case
A 13 year old female presents with a frontal HA and prior migraines that are relieved with ibuprofen
She had some AMS in the AM, with unusual motor activity (restless, thrashing on bed)
She had no other systemic sx, recent illness, or head trauma
She presented with normal vital signs and normal neurologic exam
What should the emergency physician do?
What is the expected outcome of this patient?

5. Overview Global Objectives
Learn more about pediatric seizures
Focus on peds sz etiologies
Increase awareness of Rx options
Enhance our ED management
Improve patient care & outcomes
Maximize MD & patient satisfaction

6. Overview Session Objectives
Review main peds sz types, etiologies
Briefly discuss Rx based on sz type
Discuss relevant ED peds sz cases
Summarize what Rx options exist
Discuss rational treatment decisions

7. Overview Pediatric Sz Epidemiology
Common EMS & ED problem
Szs are up to 6% of EMS encounters
Up to 1% of all ED visits are peds sz
Peds 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 seizure
1% have an afebrile sz by age 14
Highest afebrile sz rate before age 3
% of children dvlp epilepsy
SE most common before age 1

9. Overview Pediatric SE Epidemiology
Mean age 3.2 yrs, median age 1 year
61% by age 3
Etiology age dependent
25% is febrile SE
Before age 1, 75% due to acute insult
Epilepsy, fever, CNS infection common

10. Pediatric Sz Etiologies Meningitis
Altered mental status universal
Seizures in 23% of meningitis cases
Complex & GTC seizures common
Simple seizures rarely seen
HIB vaccine makes this etiology rare

11. Pediatric Sz Etiologies Hyponatremia
Causes long duration szs and SE
Infants < 6 months old, no clear etiol
Too much water in formula
Hypothermia (Temp < 36.5 degrees)

12. Pediatric Sz Etiologies Cocaine Toxicity
Consider in new onset seizures
Crack cocaine rocks ingested
Especially when no other etiology
Common in urban EDs

13. Pediatric Seizures Seizure Outcome
Immature CNS, myelinization
More prone to seizures
More resistant to consequences
Continuous seizures less toxic
SE carries a low mortality (3-6%)

14. Pediatric Seizures SE Outcome
Based on CNS status prior to SE
Normal CNS, 64% remain intact
Mortality related to two factors:
Acute neurologic insult
Chronic CNS condition

15. Pediatric Seizures Seizure Type Classification
Generalized
Involves both cerebral hemispheres
Convulsive: tonic-clonic seizures
Non-convulsive: absence seizures
Partial
Involves one cerebral hemisphere
Simple: no impaired consciousness
Complex: impaired consciousness

16. Seizure Classification Generalized Seizures
Convulsive seizures
Tonic sz: sustained contractions
Clonic sz: rhythmic flexor spasms
Tonic-clonic sz: combined mvmts
Non-convulsive
Simple absence: impaired consciousness
Complex absence: brief motor mvmts

17. Seizure Classification Partial Seizures
Simple seizures (no LOC)
Focal motor (Jacksonian)
Sensory or somatosensory
Autonomic
Psychic
Complex (impaired consciousness)
Involves some cognitive, affective sx
Temporal lobe, psychomotor seizures

18. Pediatric Seizures Other Generalized Sz Types
Neonatal seizures
Benign childhood epilepsy (Rolandic)
Infantile spasms (West syndrome)
Lennox-Gastaut syndrome
Atonic seizures
Febrile seizures

19. Pediatric Seizures Status Epilepticus Types
Convulsive SE : tonic-clonic sz
Non-convulsive SE: no tonic-clonic sz
Absence SE
Complex partial SE
Subtle SE: prolonged convulsive SE
Worst prognosis, mortality > 30%
Persistent coma, focal motor mvmts only

20. Specific Seizure Types Generalized Tonic-Clonic Sz
Seizure described as a convulsion
May occur primarily or secondarily
May be preceded by prodrome or aura
Tonic, then clonic phase
Tongue biting, urinary incontinence
Last for minutes, then post-ictal

21. Specific Seizure Types Absence Seizure
Petit mal epilepsy
Brief, limited motor activity
Sudden interruption of consciousness
Slight clonic mvmts, myoclonic jerks
Automatisms also can be seen
Last about 10 sec, not post-ictal

22. Specific Seizure Types Partial Seizure
Focal motor sz (Jacksonian, frontal)
Focus and/or lesion in cerebrum
Sz clearly related to a lesion
Sz type related to site of sz focus
CT scan is useful
Simple partial sz pts have no AMS

23. Specific Seizure Types Complex Partial Seizure
Psychomotor, temporal lobe epilepsy
Often a history of febrile seizures
Complex aura, altered behavior
Automatisms: lip smacking, chewing
Not complete LOC, instead confused
May secondarily generalize

24. Specific Seizure Types Neonatal Seizure
Occur in first 28 days of life
Most occur shortly after birth
Subtle sz: lip smack, eye mvmt, apnea
Perinatal asphyxia, metabolic abn
Hypoglycemia, hypocalcemia
CNS infection, hemorrhage, lesion

25. Specific Seizure Types Benign Childhood Epilepsy
Rolandic epilepsy
Onset between 3 and 13 years of age
Often occurs upon awakening
Facial mvmts, grimacing, vocalizations
EEG diagnosis

26. Specific Seizure Types Infantile Spasms
West syndrome
Occurs up to one year
May be symptomatic or idiopathic
Sudden tonic movements of the head, trunk, extremities
Must do full work-up, incl metabolic
Caution, AED hepatotoxicity a risk

27. Specific Seizure Types Lennox-Gastaut Syndrome
Onset from 1-8 years
Peaks at 3-5 years
Multiple seizure types
GTC, tonic, absence, atonic szs
ED Hx: exac of known sz disorder

28. Specific Seizure Types Atonic Seizures
Astatic or akinetic seizures
Sudden loss of motor tone
Child falls to the floor
May have myoclonic jerks
No clear generalized seizure
No etiology of apparent syncopal episode

29. Specific Seizure Types Febrile Seizures
Age: 6 months to 5 years
Related to rapid rise in temperature
Brief, self-limited generalized sz
Complex: Focal, > min, flurry
25% recurrence, esp if in child < 1 yr old
Risk of epilepsy not significantly greater

30. Specific Seizure Types Juvenile Myoclonic Epilepsy
Common in teens, young adults
Etiology of generalized TC seizures
History of staring spells
History of AM clumsiness, myoclonus
Sleep deprivation, EtOH precipitants
Phenytoin: worse myoclonus, absence sz

31. Specific SE Types Generalized Convulsive SE
Seizure lasting greater than 5-10 min
Refractory to initial benzo therapy
Flurry of seizures and coma
CNS injury likely after minutes
Glutamate, cell death, tissue necrosis
Injury even if systemic sx controlled

32. Specific SE Types Non-convulsive SE
No generalized tonic-clonic sz
Absence SE
Complex partial SE
No frank coma
More common in children
Not always due to co-morbidity
Mortality ?? not as high as in GCSE

33. Specific SE Types Subtle SE
Late manifestation of GCSE, frank coma
No longer with tonic-clonic mvmts
Still actively seizing (electrical SE)
Usu in older patients
Marked co-morbidity (encephalopathic)
Highest SE mortality

34. Seizure Therapy Generalized Seizure Protocol
Benzodiazepines
PR diazepam, IM midazolam, IV lorazepam
Phenytoins
Fosphenytoin can be given IV or IM
Phenobarbital or valproate
Less sedation with valproate
Propofol or midazolam infusions
EEG monitoring, BP support key

35. Seizure Therapy Ongoing Therapies
Absence: Ethosuximide, valproate
Atonic: Valproate, clonazepam, ethosuximide
Myoclonic: Valproate, clonazepam
Partial: Carbamazepine, phenytoin, valproate
Generalized: Carbamazepine, phenytoin, phenobarb, primidone, valproate

36. Case Presentations ED Pediatric Seizure Cases
Pediatric complex partial SE
New onset SE in an adolescent
New 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 spells
Some headache and shaking movement, esp of hands
Frontal headache, vomiting

39. Pediatric SE 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…”

40. Pediatric SE Px 98.7 98/60 72 20 Well hydrated CV, lung exams normal/
Well hydrated
CV, lung exams normal
Neuro exam intact

41. Pediatric SE Clinical Course
0220 “episode”
Tachycardia, BP OK, airway OK
Confused, staring off into space
Episode lasted < 5 minutes
Resolved without any Rx

42. Pediatric SE Clinical Course (con’t)
Three more episodes over 40’
Similar autonomic symptoms
Some non-purposeful ext mvmts
Diaphoresis, urinary incontinence
Remained somnolent between episodes

43. Pediatric SE Dx Repetitive episodes with AMS Autonomic symptoms noted
Non-purposeful mvmts noted
Rule out complex partial status epilepticus (CPSE)

44. Pediatric SE Rx IV lorazepam IV valproate Transfer to Children’s
ICU observation
Uncomplicated 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 ibuprofen
AMS in AM, with ?? motor activity
Restless at home, thrashing on bed
No other systemic sx or recent illness

47. Adolescent SE Px Vitals OK, afebrile Alert, O x 3, NAD Head/Neck OK
Chest/cor/abd OK
Neuro: 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 neg
CT negative
Neuro consult: EEG and then D/C
Dx: AMS, r/o Seizure; migraine HA
While EEG applied, pt with AMS
Agitation, 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 sz
Leftward gaze noted
Seizure then generalized
Meds were given
Seizure 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 Rx
Pt stabilized, still somnulent
ALS transfer team to Children’s
Pt with resolving AMS at time of D/C

60. Adolescent SE Dx New onset SE
Complex partial seizures with generalized seizure / SE
Hx migraine headaches

61. Adolescent SE Rx Lorazepam to Rx the acute sz
2mg IVP x 2
Valproate for ongoing protection
25 mg/kg load administered
Infused over 20 minutes
PRN 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 student
No prior neuro history
Final exams, sleepless
Great party after the last exam
Pt with single generalized sz
Seizure upon awakening

68. Juvenile Myoclonic Sz Px
Vitals OK
Neuro: slightly post-ictal
Exam otherwise normal
Patient has a 2nd seizure in the ED

69. Juvenile Myoclonic Sz Dx
Juvenile myoclonic epilepsy
Related to sleep deprivation, alcohol consumption
Occurs upon awakening
Responds best to valproate
Phenytoin may exacerbate sx

70. Juvenile Myoclonic Sz Rx
Benzodiazepines to Rx the acute sz
Ongoing protection an issue
Valproate is likely the drug of choice
Phenytoin may not be optimal
Avoid status epilepticus

71. Conclusions Clinical Pearls
Acute, repetitive spells = sz
Ongoing altered mental status = complex partial SE
Treat acute szs with lorazepam
Valproate is the etiology-specific ongoing Rx in many young people
Know the specific JME clinical setting

72. 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