Pediatric Emergency Conference

1. Pediatric Emergency Conference

3. Speiser, et al. New England Journal of Medicine, 2003

4. Seizures • result from rapid abnormal electrical discharges from cerebral neurons • presents clinically as involuntary alterations of consciousness or motor activity • Consumption of oxygen, glucose, and energy substrates (e.g, ATP, phosphocreatine) is significantly increased in cerebral tissue during seizures. • Optimal delivery of these metabolic substrates to cerebral tissue requires adequate cardiac output and intravascular fluid volume. Pediatric, Status Epilepticus; emedicine 2008

5. Important points in the History • The course of current seizure activity • Time and nature of onset of seizure activity • Involvement of extremities or other body parts • Nature of movements (eg, eye movements, flexion, extension, stiffening of extremities), including any focal movements and details of postictal neurologic deficit • Incontinence • Cyanosis (perioral or facial) • Duration of seizure activity prior to medical attention • Mental status after cessation of seizure activity • Fever or intercurrent illnesses • Prior history of seizures - If present, specify medications, anticonvulsant use, and compliance. Pediatric, Status Epilepticus; emedicine 2008

6. Important points in the History • Head injury (recent and remote) • CNS infection or disease (eg, meningitis, neurocutaneous syndrome) • Intoxication or toxic exposure • Other CNS abnormality (eg, ventricular-peritoneal shunt, prior CNS trauma) • Birth history and developmental delay (eg, anoxic encephalopathy, cerebral palsy) • Other medical history (eg, acquired immunodeficiency syndrome, systemic lupus erythematosus, type 1 diabetes mellitus) Pediatric, Status Epilepticus; emedicine 2008

7. Important points in the PE • Signs of sepsis or meningitis • Temperature more than 38.5°C; in patients younger than 2-3 months, more than 38.0°C • Respiratory distress • Cyanosis • Poor peripheral perfusion • Bulging fontanelles in infant • Meningismus (in children >12-18 mo) • Presence of petechiae or purpura, herpetic vesicles • Evidence of head or other CNS injury • Bradycardia, tachypnea, and hypertension (Cushing triad for signs of increased intracranial pressure) • Poor pupillary response • Asymmetry on neurologic examination • Abnormal posturing • Gross deformity or soft tissue injury to head • Hallmarks of neurocutaneous syndromes (e.g., port wine stain) Pediatric, Status Epilepticus; emedicine 2008

8. Monitoring of Vital Functions • Respiratory rate, blood pressure, cardiac rate • Observation of seizure activity • Skin bruises, petechiae or needle marks • Papilledema, retinal hemorrhages • Organomegaly and abdominal tenderness

9. Factors that lower Seizure Threshold • Sleep deprivation • Hyperventilation • Photic stimulation • Infection • Metabolic disturbances • Head trauma • Cerebral ischemia • Kindling Handbook of Neurosurgery by Greenberg

10. Status Epilepticus • Continuous clinical or electroencephalographic seizures lasting for at least 30 minutes or recurrent seizures without return of consciousness during interictal period: the series lasting for 30 minutes or more. It is a medical emergency. Handbook of Medical & Surgical Emergencies, 6th edition

11. Clinical Classification of Status Epilepticus Handbook of Medical & Surgical Emergencies, 6th edition

12. Types of Status Epilepticus • Generalized Status • Convulsive: generalized convulsive tonic-clonic status epilepticus (SE) is the most frequent type • Absence • Secondarily generalized: accounts for ~75% of generalized SE • Myoclonic • Atonic (drop attack): especially in Lennox-Gastaut syndrome • Partial Status (usually related to anatomic abnormality) • Simple (Epilepsy Partialiscontinuans) • Complex • Secondarily generalized Handbook of Neurosurgery by Greenberg

13. Etiologies • Febrile seizures • Cerebrovascular accidents • CNS infection • Idiopathic • Epilepsy • Subtherapeutic antiepileptic drug • Electrolyte imbalance • Drug intoxication • Alcohol withdrawal • Traumatic brain injury • Anoxia • Tumor Handbook of Neurosurgery by Greenberg

14. DIFFERENTIAL DIAGNOSIS Pediatric, Status Epilepticus; emedicine 2008

15. In children < 1year age 75% acute cause 30% electrolyte disorders 28% secondary to CNS infection 19% associated with fever Handbook of Neurosurgery by Greenberg

16. Prolonged seizures are associated with cerebral hypoxia, hypoglycemia, and hypercarbia and with concurrent and progressive lactic and respiratory acidosis. When cerebral metabolic needs exceed available oxygen, glucose, and metabolic substrates (especially during status epilepticus), neuronal destruction can occur and may be irreversible. Hypoxia, hypercarbia, hyperthermia, tachycardia, hypertension, hyperglycemia, hyperkalemia, and lactic acidosis result from massive sympathetic discharge. Pediatric, Status Epilepticus; emedicine 2008

17. Prolonged seizures Life threatening systemic changes Temporary systemic changes Death Duration of seizure Werner, MD; GTC SE in Children; University of Kentucky Hospital

18. Mortality • The primary determinant of mortality and morbidity of SE in children is its etiology • The greatest mortality and highest rate of neurological deficits occurs when SE is caused by an acute neurological condition (infection, trauma, stroke) Mitchell WG. J Child Neurol 2002;17 Suppl 1:S36-43.

19. Mean duration of SE in patients without neurologic sequelae is 1.5hours. Mortality is lowest among children (~6%) subtherapeutic AEDs unprovoked SE Highest Mortality elderly patients SE due to anoxia or CVA Handbook of Neurosurgery by Greenberg

20. Etiopathogenesis