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Pediatric Seizure and SE Patient ED Care: Challenging 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.
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Pediatric Seizure and SE Patient ED Care:Challenging 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 University of Illinois Hospital Our Lady of the Resurrection Hospital Chicago, IL Edward P. Sloan, MD, MPH, FACEP 3
Housekeeping Issues • Disclosures • Meeting support from UCB Pharma • Thank you Dave Riccio • IV levetiracetam, 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
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%)
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
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
Case #1:Seizing infant, no IV access • What therapies can be given? • By what route? • With what effect?
Case #1Hx • 9 month old • Febrile illness at home • Seizing for paramedics • Arrives in arms of CFD • No IV access in field
Case #1Px • Hyperpyrexia, abn vital signs • Actively seizing, generalized • Tonic-clonic motor activity • Cardiopulm exam OK • No IV access available
Case #1Dx • What are the diagnoses in this child?
Case #1Dx • Generalized convulsive status epilepticus (GCSE) • Complex febrile seizure
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
Case #1Rx: Non-IV Options • IM midazolam • Buccal midazolam • IM fosphenytoin • PR diazepam • PR diazepam rectal gel • IM phenobarbital less good
Case #2: Pediatric SE • How do we diagnose ped SE? • What is the optimal Rx protocol? • Why?
Case #2Hx • 7 year old male • Seizure-like activity? • Patient with staring spells • Some headache and shaking movement, esp of hands • Frontal headache, vomiting
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…”
Case #2Px • 98.7 98/60 72 20 • Well hydrated • CV, lung exams normal • Neuro exam intact
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
Case #2Dx What is the likely diagnosis in this pediatric patient? • Absence status epilepticus • Complex partial status epilepticus (CPSE) with autonomic signs • Generalized non-convulsive seizure with autonomic signs • Generalized convulsive SE
Case #2Dx • Repetitive episodes with AMS • Associated autonomic signs • Rule out generalized nonconvulsive status epilepticus • Complex partial status epilepticus • Absence status epilepticus
Case #2Rx How would you initially treat this pediatric seizure patient? • IV diazepam • IV lorazepam • IV phenobarbital • IV valproate • Rectal diazepam
Case #2Rx Would you load this patient with another antiepileptic drug prior to transfer to the children’s hospital? • Yes • No
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
Case #2Rx • IV lorazepam • IV valproate • Transfer to Children’s for ICU observation
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?
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
Case #3Px • VS OK prior to seizure • Chest: Clear • CV: Reg without • Neuro: Non-focal • Generalized tonic-clonic seizure
Case #3Dx • Generalized seizures • Hx complex partial seizures • Sub-therapeutic valproate level vs. break-thru seizure
Case #3Rx After an initial dose of a benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate? • Yes • No
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
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
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?
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
Case #4Px • Vitals OK • Neuro: slightly post-ictal • Exam otherwise normal • Patient has a 2nd seizure in the ED
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
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
Case #4Rx • Benzodiazepines to Rx the acute sz • Ongoing protection an issue • Phenytoin may not be optimal • Valproate may be preferred • Avoid status epilepticus
Case #5:New Onset AMS/Spells • What is the AMS? • Is it a seizure? • How should we Rx new onset seizure patients? • What role does the ED EEG play in sz and SE?
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
Case #5Px • Vitals OK, afebrile • Alert, O x 3, NAD • Head/Neck OK • Chest/cor/abd OK • Neuro: No focal deficit. MS OK
Case #5Question # 1 • What diagnostic tests are indicated at this point?
Case #5Question # 2 Did this patient have a seizure? • Yes • No
Case #5Question # 3 Does the patient require admission for observation for possible new onset seizures? • Yes • No
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
Case #5Question # 4 • Is this repeat spell a seizure? • What type?
Case #5Question # 5 • Does this AMS, motor activity require Rx? • What Rx?
Case #5Question # 6 • Does the patient require admission for observation for possible new onset seizures?
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
Case #5Question # 7 • What med is to be used for seizure control / SE termination?