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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting

Pediatric Seizure and Status Epilepticus Management in the Emergency Setting. Edward P. Sloan, MD, MPH Associate Professor & Research Development Director Dept of Emergency Medicine. University of Illinois College of Medicine Chicago, IL. Attending Physician Emergency Medicine.

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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting

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  1. Pediatric Seizure and Status Epilepticus Managementin the Emergency Setting

  2. Edward P. Sloan, MD, MPHAssociate Professor & Research Development DirectorDept 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 & SEClinical 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. 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

  6. OverviewSession 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. 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%)

  8. 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 dvlp epilepsy • SE most common before age 1

  9. OverviewPediatric 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 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

  11. Pediatric Sz EtiologiesHyponatremia • 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 EtiologiesCocaine Toxicity • Consider in new onset seizures • Crack cocaine rocks ingested • Especially when no other etiology • Common in urban EDs

  13. 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%)

  14. 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

  15. 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

  16. Seizure ClassificationGeneralized 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 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

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

  19. 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

  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, > 10-15 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 30-40 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 PresentationsED 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 SEHx • 7 year old male • Seizure-like activity? • Patient with staring spells • Some headache and shaking movement, esp of hands • Frontal headache, vomiting

  39. Pediatric SEHx (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 SEPx • 98.7 98/60 72 20 • Well hydrated • CV, lung exams normal • Neuro exam intact

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

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

  44. Pediatric SERx • 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 SEHx • 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 SEPx • Vitals OK, afebrile • Alert, O x 3, NAD • Head/Neck OK • Chest/cor/abd OK • Neuro: No focal deficit. MS OK

  48. Adolescent SEQuestion # 1 • What diagnostic tests are indicated at this point?

  49. Adolescent SEQuestion # 2 • Did the patient have a seizure? • Does it influence Dx, Rx?

  50. Adolescent SEQuestion # 3 • Does the patient require admission for observation for possible new onset seizures?

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