Paediatric emergency department topic 1 Dr Julia Thomson General paediatric consultant with an interest in Emergency Pae

1. Paediatric emergency department topic 1Dr Julia ThomsonGeneral paediatric consultant with an interest in Emergency Paediatrics Emergency Management of the convulsing child Febrile convulsions

2. Emergency management of the convulsing childLearning objectives • Assessment and support of the convulsing child • Termination of a tonic-clonic convulsion

3. Background • Generalised convulsive (tonic-clonic) status epilepticus definition • Generalised convulsion lasting 30 minutes or more or frequent successive convulsions over a period of 30 minutes or more with no regaining of consciousness in between. • Outcome determined by underlying cause and by duration • > 5 minutes unlikely to terminate spontaneously • Mortality in children from status epilepticus is about 4% • Airway obstruction, hypoxia, aspiration of vomit, overmedication, cardiac arrhythmias, underlying disease process

4. Assessment of the convulsing child • Assess and if necessary support • A,B,C • AIRWAY • BREATHING • CIRCULATION

5. Assessment 2 • DISABILITY • EXPOSURE • F • G • Glucose!!

6. Termination of seizure Wait 10 minutes -> <- Most children stop fitting by this point If still in status 20 mins after phenytoin started anaesthetist needs to draw up their drugs

7. Questions on emergency management of a convulsing child

8. Summary • Assessment and support of the convulsing child • ABC DEFG • 2222 • airway positioning +/- suction • O2 • glucose, fluid, antibiotics as required • Termination of a tonic-clonic convulsion • algorithm

9. Worksheet

10. Febrile convulsions Information from the Paediatric Epilepsy Training (PET 1) Manual, produced by BPNA

11. Febrile convulsions learning objectives • Understand the definition of and some background to febrile convulsions • Be able to recognise whether a febrile seizure is simple or complex • Have an idea of what to say to parents including the risk of recurrence and the risk of developing epilepsy

12. definition “an event occurring in infancy or childhood, usually between 3 months and 5 years of age, associated with a fever but without evidence of intracranial infection or defined cause for the seizure” National Institute for Health, USA

13. definition “an event occurring in infancy or childhood, usually between 3 months and 5 years of age, associated with a fever but without evidence of intracranial infection or defined cause for the seizure” National Institute for Health, USA • Lower and upper age limits vary according to the source • Presentation with 1st febrile seizure is rare after 5 years of age • Peak incidence of first one is 9 to 20 months

14. definition “an event occurring in infancy or childhood, usually between 3 months and 5 years of age, associated with a fever but without evidence of intracranial infection or defined cause for the seizure” National Institute for Health, USA • No definition for “fever” • Generally accepted as at least 38oC • Fitting at lower temperatures is one of the factors to take into account when assessing the risk of recurrence

15. definition “an event occurring in infancy or childhood, usually between 3 months and 5 years of age, associated with a fever but without evidence of intracranial infection or defined cause for the seizure” National Institute for Health, USA • 1% of patients who have had a fit and have a high temperature have meningitis or encephalitis. These are therefore not febrile fits by definition.

16. definition “an event occurring in infancy or childhood, usually between 3 months and 5 years of age, associated with a fever but without evidence of intracranial infection or defined cause for the seizure” National Institute for Health, USA • Children with other neurological conditions, eg. CP, may fit when febrile. These also should not be diagnosed as “febrile convulsions”.

17. Classification of febrile seizures SIMPLE COMPLEX 70% of febrile fits accounts for 30% last under 10 minutes last more than 10 minutes generalised focal features do not recur within 24 hours nor do recur within the same during the same illness illness

18. Genetics • Strong genetic basis for febrile seizures • Risk to sibling of a child with febrile fits is 25% • High concordance in monozygotic twins • ?autosomal dominant, ?effect of multiple genes, ?mutations in specific genes • Ask about the family history

19. Parents questions 1 • Do lots of children get febrile seizures? • They are common; by 7 years, 3-4% of children will have had 1 or more febrile seizures • Boys > girls, black children > white children

20. Parents questions 2 • What is the chance that it will happen again? • The overall recurrence risk is 30-40% • Predictors of risk are: • Age less than 18 months • Family history of febrile seizures • Low temperature at the time of the seizure • Short duration of illness • The number of the above risk factors present determines the likelihood of recurrence: • No risk factors = 4% recurrence risk • 1 risk factor = 23% • 2 risk factors = 32% • 3 risk factors = 62% • 4 risk factors = 76%

21. Parents questions 3 • How dangerous are they? • Other than a potential risk of injury, short febrile seizures are not dangerous and will not cause brain damage • Febrile seizures lasting over 30 minutes can be associated with appreciable morbidity and mortality

22. Parents questions 4 • Has my child got epilepsy? • In the vast majority of cases febrile seizures will not be followed by epilepsy • The background population risk of epilepsy is 0.5%. The overall risk for children who have a febrile fit is a six-fold increase on this ie. 3% • Risk factors for developing epilepsy include: • Prior abnormal neurodevelopment • Family history of afebrile seizures • Complex febrile seizure • Likelihood increases with the number of risk factors: • No risk factors = same as population risk (0.5%) • 1 risk factor = 6-8% • All 3 risk factors = almost 50%

23. Questions on febrile convulsions

24. Febrile convulsions summary • Definition of febrile fit • Discussed whether a febrile seizure is classified as simple or complex • Have thought about what to say to parents including the risk of recurrence and the risk of developing epilepsy