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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois Chicago, IL. Case.

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  1. Pediatric Seizure and Status Epilepticus Management in the Emergency SettingEdward P. Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of IllinoisChicago, IL

  2. Case A 7-year old boy presents to the ED with a history of staring spells, some shaking movements, and headache over the past day. He has no history of seizures or epilepsy. In the ED, he has three episodes of tachycardia, staring and confusion that last several minutes and resolve without therapy. He then has a similar episode associated with diaphoresis and urinary incontinence. His most likely diagnosis is:

  3. Most likely diagnosis: • Absence status epilepticus • Complex partial status epilepticus • Benign childhood epilepsy • Lennox-Gastaut syndrome • Generalized convulsive status epilepticus

  4. Assuming that the above episodes in the 7-year old represent repeated seizures, all of the following are acceptable initial therapies except: • Rectal diazepam • Rectal diazepam gel • IM midazolam • IV lorazepam • IV phenobarbital

  5. Case A 13-year old female presents at mid-morning to the ED with a one-day history of a frontal headache, consistent with prior migraines, that was relieved with ibuprofen. She also was noted by family members to be restless in bed, and was noted to “thrash about for a brief period of time.” The family denied that this was a generalized seizure, and denied any history of epilepsy, trauma, drug ingestion, or similar episodes. The patient has a similar episode in the ED, and then has a generalized seizure.

  6. Most likely diagnosis: • Primary generalized seizure • Absence seizure • Complex partial seizure with secondary generalization • Juvenile myclonic epilepsy • Non-convulsive status epilepticus

  7. Case A 21-year old male college student presents in the early morning to the ED with a one-day history of having a generalized seizure upon awakening. The patient had been partying after final exams, and had not been getting much sleep for several days. Over the phone, his mom noted that he had a history of “staring spells” as a child.

  8. Most likely diagnosis: • Primary generalized seizure • Absence seizure • Complex partial seizure with secondary generalization • Juvenile myoclonic epilepsy • Non-convulsive status epilepticus

  9. The above 21-year old patient had two seizures in the ED which were controlled with lorazepam. If a load of a longer acting AED was to be given in the ED in order to prevent status epilepticus, what would be the optimal drug to administer?

  10. Most optimal drug: • IV midazolam • IV phenytoin • IV fosphenytoin • IV valproate • IV phenobarbital

  11. What is the optimal loading dose of IV valproate in patients at risk for SE? • 1-5 mg/kg • 10-15 mg/kg • 20-30 mg/kg • 90-100 mg/kg

  12. If an IV valproate load of 25 mg/kg were given to this patient, what would be the expected valproate level once the infusion had ended?

  13. Expected IV Valproate level? • 25 mg/L • 50 mg/L • 75 mg/L • 100 mg/L • 125 mg/L

  14. If this patient were to develop status epilepticus, what is the fastest time of infusion possible for a loading valproate infusion of 2500 mg (25 mg/kg x 100 kg)?

  15. Fastest Infusion Time Possible? Fastest Infusion Time Possible? • 4 minutes (6 mg/kg/minute) • 8 minutes (3 mg/kg/minute) • 24 minutes (1 mg/kg/minute) • 2 minutes (0.3 mg/kg/minute) • 216 minutes (0.1 mg/kg/minute)

  16. OverviewGlobal 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

  17. OverviewPediatric 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%)

  18. OverviewPediatric Sz Epidemiology • 2-5% have a febrile seizure • 1% have an afebrile sz by age 14 • Highest afebrile sz rate before age 3 • 0.4-0.8% of children develop epilepsy • SE most common before age 1

  19. OverviewPediatric Sz 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

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

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

  22. Cocaine Toxicity • Consider in new onset seizures • Crack cocaine rocks ingested • Especially when no other etiology • Common in urban EDs

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

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

  25. Pediatric SeizuresSeizure 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

  26. Seizure ClassificationGeneralized Seizures • Convulsive seizures • Tonic sz: sustained contractions • Clonic sz: rhythmic flexor spasms • Tonic-clonic sz: combined movements • Non-convulsive • Simple absence: impaired consciousness • Complex absence: brief motor mvmts

  27. Seizure ClassificationPartial 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

  28. Pediatric SeizuresOther Generalized Sz Types • Neonatal seizures • Benign childhood epilepsy (Rolandic) • Infantile spasms (West syndrome) • Lennox-Gastaut syndrome • Atonic seizures • Febrile seizures

  29. Pediatric SeizuresStatus 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

  30. Specific Seizure TypesFebrile Seizures • Age: 6 months to 5 years • Related to rapid rise in temperature • Brief, self-limited generalized sz • Complex: Focal, > 10-15 min, flurry • 25% recurrence, esp if in child < 1 yr old • Risk of epilepsy not significantly greater

  31. Specific Seizure TypesJuvenile 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

  32. Specific Seizure TypesGeneralized Convulsive SE • Seizure lasting greater than 5-10 min • Refractory to initial benzo therapy • Flurry of seizures and coma • CNS injury likely after 30-40 minutes • Glutamate, cell death, tissue necrosis • Injury even if systemic sx controlled

  33. Specific Seizure 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

  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 • Myclonic: valproate, clonazepam • Partial: carbamazepine, phenytoin, valproate • Generalized: carbamazepine, phenytoin, phenobarb, primidone, valproate

  36. Case PresentationED Pediatric Seizure Cases • Pediatric complex partial SE • New onset SE in an adolescent • New onset sz in a college student

  37. 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

  38. Pediatric SE Hx (cont.) • 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…”

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

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

  41. Pediatric SE Clinical Course (cont.) • Three more episodes over 40’ • Similar autonomic symptoms • Some non-purposeful ext mvmts • Diaphoresis, urinary incontinence • Remained somnolent between episodes

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

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