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Challenging Pediatric Seizure and SE Cases

Challenging Pediatric Seizure and SE Cases. Edward P. Sloan, MD, MPH, FACEP. 1. Edward P. Sloan, MD, MPH. Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL. Edward P. Sloan, MD, MPH, FACEP. 2. Attending Physician Emergency Medicine.

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Challenging Pediatric Seizure and SE Cases

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  1. Challenging Pediatric Seizure and SE Cases Edward P. Sloan, MD, MPH, FACEP 1

  2. Edward P. Sloan, MD, MPH Professor Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL Edward P. Sloan, MD, MPH, FACEP 2

  3. Attending Physician Emergency Medicine University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL Edward P. Sloan, MD, MPH, FACEP 3

  4. Housekeeping Issues • Disclosures • Meeting support from UCB Pharma • Thank you Dave Riccio • IV levitiracetam, a second generation AED • May soon be an IV parenteral option in the ED • Please fill out a CME form with your email • Please give feedback to improve our work

  5. OverviewAcute Pediatric Seizures • Common ED problem • Seizures: 6% of EMS encounters • Pediatric seizures: 1% of all ED visits • Pediatric febrile: 1 in 125 visits (0.8%) • Pediatric afebrile: 1 in 500 visits (0.2%)

  6. ObjectivesManagement Issues • Learn likely sz etiologies • Seizure Rx without IV access • Review seizure termination Rx • Explore IV Rx for SE prevention • Review EEG in E.D. SE • Discuss clinical impact

  7. Case PresentationsED Pediatric Seizure Cases • Seizing infant, no IV access • Pediatric status epilepticus • Adolescent sz pt with seizures • College student with new onset sz • New onset SE in an adolescent • Discussion

  8. Case #1:Seizing infant, no IV access • What therapies can be given? • By what route? • With what effect?

  9. Case #1Hx • 9 month old • Febrile illness at home • Seizing for paramedics • Arrives in arms of CFD • No IV access in field

  10. Case #1Px • Hyperpyrexia, abn vital signs • Actively seizing, generalized • Tonic-clonic motor activity • Cardiopulm exam OK • No IV access available

  11. Case #1Dx • What are the diagnoses in this child?

  12. Case #1Dx • Generalized convulsive status epilepticus (GCSE) • Complex febrile seizure

  13. Case #1Rx: Non-IV Options What treatment would you provide for this patient? • PR diazepam or rectal gel • Buccal midazolam • IM fosphenytoin • IM midazolam • IM phenobarbital

  14. Case #1Rx: Non-IV Options • IM midazolam • Buccal midazolam • IM fosphenytoin • PR diazepam • PR diazepam rectal gel • IM phenobarbital less good

  15. Case #2: Pediatric SE • How do we diagnose ped SE? • What is the optimal Rx protocol? • Why?

  16. Case #2Hx • 7 year old male • Seizure-like activity? • Patient with staring spells • Some headache and shaking movement, esp of hands • Frontal headache, vomiting

  17. Case #2Hx (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…”

  18. Case #2Px • 98.7 98/60 72 20 • Well hydrated • CV, lung exams normal • Neuro exam intact

  19. Case #2Px (con’t) • 0220 “episode” • Tachycardia, assoc with AMS • Confused, staring off into space • Resolved without any Rx • Three more episodes over 40’ • Diaphoresis, urinary incontinence

  20. Case #2Dx What is the likely diagnosis in this pediatric patient? • AMS, no seizure disorder • Complex partial status epilepticus (CPSE) with autonomic signs • Generalized non-convulsive seizure with autonomic signs • Generalized convulsive SE

  21. Case #2Dx • Repetitive episodes with AMS • Rule out generalized nonconvulsive status epilepticus • Rule out complex partial status epilepticus • Associated autonomic signs

  22. Case #2Rx How would you initially treat this pediatric seizure patient? • IV diazepam • IV lorazepam • IV phenobarbital • IV valproate • Other

  23. Case #2Rx Would you load this patient with another antiepileptic drug prior to transfer to the children’s hospital? • Yes • No

  24. Case #2Rx If you were to load this patient with an AED, what agent would you use? • IV phenytoin • IV fosphenytoin • IV phenobarbital • IV valproate • Other

  25. Case #2Rx • IV lorazepam • IV valproate • Transfer to Children’s for ICU observation

  26. Case #3: Adolescent Sz Pt with Seizures • How to manage seizing children on PO valproate? • Does a level need to be checked prior to ED loading? • When and how to rapidly restore a therapeutic level?

  27. Case #3Hx • 12 yo F • Hx autism • Hx complex partial seizures • Hx secondary generalized tonic-clonic seizures • Pt taking Depakote sprinkles BID • Presents to ED, has 2nd seizure

  28. Case #3Px • VS OK prior to seizure • Chest: Clear • CV: Reg without • Neuro: Non-focal • Generalized tonic-clonic seizure

  29. Case #3Dx • Generalized seizures • Hx complex partial seizures • Sub-therapeutic valproate level vs. break-thru seizure

  30. Case #3Rx After an initial dose of a benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate? • Yes • No

  31. Case #3Rx To achieve a high therapeutic level of 125 ucg/ml, if the measured level is 25 ucg/ml, how much IV valproate should be administered in mg/kg ? • 100 mg/kg • 50 mg/kg • 20 mg/kg • 5 mg/kg

  32. Case #3Rx • IV lorazepam, avoid status epilepticus • Determine valproate level • For every mg/kg loaded, the level goes up 5 mcg/ml • To increase the level by 100 mcg/ml, give 20 mg/kg. For a 50 kg child, give 1000 mg of IV valproate

  33. Case #4: College Student, New Onset Sz • What is the likely etiology? • What are the long-term implications? • How to manage once the seizure has stopped?

  34. Case #4Hx • 21 year old college student • No known neuro history • Final exams, sleepless • Great party after the last exam • Pt with single generalized seizure in am, upon awakening

  35. Case #4Px • Vitals OK • Neuro: slightly post-ictal • Exam otherwise normal • Patient has a 2nd seizure in the ED

  36. Case #4Dx What is the likley diagnosis in this young adult? • Complex partial seizures with secondary generalization • Juvenile myoclonic epilepsy • Generalized tonic-clonic seizure • Absence seizure

  37. Case #4Dx • Juvenile myoclonic epilepsy • Related to sleep deprivation, alcohol consumption, occurs upon awakening • May have a history of myoclonic jerks • Responds long-term best to valproate

  38. Case #4Rx • 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

  39. Case #5:New Onset AMS/Spells • What is the AMS? • Is it a seizure? • How should we Rx new onset szs? • What role does the E.D. EEG play in sz and SE?

  40. Case #5Hx • 13 year old female • HA, frontal, cw prior migraines • HA relieved with ibuprofen • AMS this AM, with ? motor activity • Restless at home, thrashing on bed • No other systemic sx

  41. Case #5Px • Vitals OK, afebrile • Alert, O x 3, NAD • Head/Neck OK • Chest/cor/abd OK • Neuro: No focal deficit. MS OK

  42. Case #5Question # 1 • What diagnostic tests are indicated at this point?

  43. Case #5Question # 2 Did this patient have a seizure? • Yes • No

  44. Case #5Question # 3 Does the patient require admission for observation for possible new onset seizures? • Yes • No

  45. Case #5Clinical Course • Labs, tox screen neg • CT negative • Neuro consult: EEG and then D/C • Dx: Seizure, migraine HA • While EEG applied, pt with AMS • Agitation, thrashing on cart

  46. Case #5Question # 4 • Is this repeat spell a seizure? • What type?

  47. Case #5Question # 5 • Does this AMS, motor activity require Rx? • What Rx?

  48. Case #5Question # 6 • Does the patient require admission for observation for possible new onset seizures?

  49. Case #5Clinical Course (con’t) • During EEG, pt with R face focal sz • Leftward gaze noted • Seizure then generalizes • Meds are given • Seizure is terminated

  50. Case #5Question # 7 • What med is to be used for seizure control / SE termination?

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