pediatric neurologic emergencies

1. pediatric neurologic emergencies may 2002 core rounds

2. contents • seizures • approaches to • febrile seizure • new onset non-febrile seizure • established seizure disorder with recurrence • neonatal seizures • status epilepticus • investigation, treatment, disposition • headache • discussion (as little evidence to support) • migraine treatment • imaging indications

3. case 1 • 2 year old • parents “shaking episode” lasting “10 mins” • EMS called - child no longer shaking • V/S - BP 105/60 HR 100 RR 18 Sat N T39 • approach? • well looking child • first event • multiple events • sick looking child

4. case 2 • 8 year old • parents describe good history for tonic-clonic activity lasting 2 mins • 1st event • post event confusion - improving • in ED - V/S N, N sensorium, N neuro exam • otherwise healthy, no meds, no allergies • approach?

5. case 3 • 16 year old • known seizure disorder, on phenytoin • typical seizure presenting complaint • V/S N, neuro N, otherwise looks well • approach?

6. case 4 • 2 week old • parents - “doesn’t look right”, “mouth opening and closing” • one episode lasting 1 minute • child not interested in feeding, sleepy • V/S - BP 90/50 HR 130 RR 38 sat N T 37.8 • otherwise normal exam • approach?

7. definitions • febrile seizure – NIH defn - event of infancy/childhood, typically between age 3mo and 5yrs, with no evidence intracranial infection or defined cause • epilepsy - two or more seizures not provoked by a specific event such as fever, trauma, infection, or chemical change

8. definitions • neonatal seizure – in first 28 days of life (typically first few days) • status epilepticus • seizure lasting >30 mins • NB rosen 5-10 mins • sequential seizures without regain LOC >30min

9. classification • generalized • LOC • tonic, clonic, tonic-clonic, myoclonic, atonic, absence • partial – focal onset • simple partial – no LOC • complex partial – LOC • partial secondarily generalized • unclassified

10. etiology • infectious • metabolic • traumatic • toxic • neoplastic • epileptic • other

11. differential diagnosis • syncope • breath holding • sleep disorders (eg. narcolepsy) • paroxysmal movement disorder • tics,tremors • migraines • psychogenic seizures

12. approach to febrile seizuresthe numbers • epidemiology • age 3mo – 5yrs • peak age 9-20 mo • 2-5% children will have before age 5 • 25-40% will have family history • 80 – 97% simple • 3 - 20% complex

13. simple febrile seizure • < 15 mins • no focal features • no greater than 1 episode in 24h • neurologically and developmentally normal

14. complex febrile seizure • >15 min • febrile epilepticus >30min or recurrent without regaining consciousness > 30min • focal • recurrence within 24h

15. what do parents want to know? • recurrence • risk recurrence 25-50% • risk recurrence after 2nd – 50% • most recurrences within 6-12 mo • (20% within same febrile illness) • risk of epilepsy • 2-3% (baseline 1%) • increased in • family history of epilepsy • abnormal developmental status • complex febrile seizure

16. neonatal seizure • brief and subtle • eye blinking • mouth/tongue movements • “bicycling” motion to limbs • typically sz’s can’t be provoked/consoled • autonomic changes • EEG less predictable

17. neonatal seizure • etiology • hypoxic-ischemic encephalopathy • Presents within first day • congenital CNS anomalies • intracranial hemorrhage • electrolyte abnormalities – hypoglycemia and hypocalcemia • infections • drug withdrawal • pyrodoxine deficiency

18. status epilepticus • definition • deizure lasting >30 mins • NB Rosen 5-10 mins • sequential seizures without regain LOC >30min • mortality in pediatric status epilepticus 4% • morbidity may be as high as 30%

19. SE treatment considerations • ABC’s • brief directed Hx and Px • glucose • antibiotics/antivirals • if meningitis/encephalitis considered

20. SE treatment • 1st line anticonvulsants • IV • lorazepam 0.1mg/kg • diazepam 0.2 mg/kg • midazolam 0.2 mg/kg • rectal diazepam • 2-5 yrs – 0.5 mg/kg • 6-11 yrs – 0.3 mg/kg • >12 yrs – 0.2 mg/kg • IM, intranasal, buccal midazolam

21. SE treatment • 2nd line agents • phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min) • fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min) • 3rd line agents • phenobarbital 20mg/kg @ 100mg/min • repeat prn 5-10mg/kg • maximum 40 mg/kg or 1 gram

22. refractory SE treatment • consider midazolam • 0.2 mg/kg bolus • then 1-10 mcg/kg/min infusion • induce barbiturate coma • pentobarbital 5-15 mg/kg @ 25 mg/min • then 1-5 mg/kg/hour • others • valproic acid • paraldehyde, chloral hydrate • propofol, inhalational anesthesia, paralysis • lidocaine

23. approach – stable post sz • history • pre-seizure • what was child doing when attack occurred • precipitants – fever, trauma, poisoning, drug/med use • aura • deizure • what movements – incl. eyes • how long • LOC? • consequences – resp distress, incontinence, injury • post seizure • Post-ictal

24. approach to stable patient • physical directed towards • systemic disease • infection • toxic exposure • focal neuro signs

25. laboratory • blood glucose? • electrolytes? • magnesium, calcium? • anything at all? • what about first time seizures? recurrent?

26. laboratory • yes if… • neonatal • abnormal mental status persistent • diabetics, renal disease • diuretic use • dehydration • malnourishment

27. laboratory • septic work-up (CBC, BC, urine C+S, CXR, LP) • as indicated • sick child • < 12 - 18 mo • therapeutic drug levels • other • ABG • toxicologic screen • TORCH, ammonia, amino acids in neonate • CPK, lactate, prolactin – ?confirm seizure?

28. lumbar puncture • patients at greatest risk for meningitis • under 18 months of age • seizure in the ED • focal or prolonged seizure • seen a physician within the past 48 hours • other indications • concern about follow-up • prior treatment with antibiotics • The American Academy of Pediatrics • “strongly consider” in infants under 12 months of age with a first febrile seizure

29. neuroimaging • WHO? which patients? • WHAT? CT vs. MRI • ultrasound in neonates • WHEN? emergent vs. elective

30. ACEP guidelines - >6 yo • consensus indication for non-contrast CT • first time seizure patients • if suspect structural lesion • partial onset seizure • age > 40 • no other identified cause • recurrent seizure patients • change in pattern • prolonged post-ictal period • worsening mental status

31. neuroimaging • predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures • Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23 • retrospective case series • predicts CT scan results normal if • no underlying high-risk condition • malignancy, NCT, recent CHI, or recent CSF shunt revision • older than 6 months • sustained a seizure of 15 minutes or less • no new-onset focal neurologic deficit • not prospectively validated

32. emergent EEG? • not generally available on emergent basis • but consider in.. • persistent altered mental status (?non convulsive status epilepticus) • paralyzed patients • pharmacologic coma

33. disposition • can be discharged home if • single seizure • stable, returning to baseline neuro status • no underlying condition/cause requiring treatment in hospital • arranged follow-up

34. EEG – 1st non-febrile seizure • follow-up EEG • within 24h • Lancet 1998;352:1007-11 • improved pick-up 51% vs 34% • ? how soon do we get ours ? • inter-ictal EEG’s often normal • neuro may do sleep deprivation study (provocation) • absence epilepsy and infantile spasms are invariably associated with an abnormal EEG • spike and wave 3HZ

35. idiopathic seizure • recurrence risk stratification • normal EEG – 25% • abN EEG – 60% • 2nd seizure – 75%

36. neuroimaging • MRI superior • not emergently available • ?defer imaging until follow-up MRI available in low risk patients?

37. treatment • correct underlying pathology, if any • antipyretics ineffective in febrile seizure • anti-epileptic choice often trial and error • no anti-epileptic 100% effective • febrile seizure – diazepam, phenobarbital, valproic acid • Currently AAP does not recommend • neonatal - phenobarbital • generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid, primidone • absence – ethosuximide, valproic acid • new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate, tiagabine, vigabatrine • in consultation with neurologist

38. pediatric headache

39. case 5 • 14 year old • mother’s chief complaint - “having headaches all the time, getting worse, this is not normal!!” etc. etc…….. • V/S N • looks in discomfort but otherwise well • approach? • treatment • imaging?

40. classification • classify based on temporal pattern • acute headaches • any febrile illness, sinus/dental infection, intracranial infection/bleed (AVM,SAH,trauma) • acute recurrent • chronic progressive • chronic non-progressive • tension, psychogenic, post-traumatic, ocular refractive error

41. acute recurrent headache • migraine • other • cluster headache – typically >10 yo • sinusitis • vascular malformation

42. migraine - terminology • classic migraine • biphasic • neuro aura • headache, N/V, anorexia, photophobia • either unilateral (older) / bilateral(younger) or both • common migraine • malaise, dizziness, N/V, feels and looks sick • unilateral/bilateral • migraine equivalent/”complicated migraine” • transient neuro deficits • +/- headache • migraine variants • Cyclic N/V, abdo pain • BPV

43. migraine treatment • very little supporting evidence for pharmacologic treatment in children compared to adults • classes of medication • acetaminophen • NSAIDS • phenothiazines (dopamine antagonists) • dihydroergotamine • triptans

44. the simple stuff • acetaminophen 15 mg/kg PO 30mg/kg PR • ibuprofen 10 mg/kg PO • Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover study Neurology 48:103-107, 1997 • N = 88 age 4-16 • relief at 2 hours • acetaminophen 54% • ibuprofen 68%

45. other NSAIDS • naproxen 5-7 mg/kg PO • no pediatric evidence • ketorolac IV 0.5 mg/kg (max 30mg dose) • not studied in pediatric migraine • not approved <16 yo • Houck CS – Safety of intravenous ketorolac in children and cost savings with a unit dosing system.J Pediatr - 01-Aug-1996; 129(2): 292-6 • 1747 children • 0.2% hypersensitivity • 0.1% renal complications (in patients with renal disease) • 0.05% gi bleed

46. dihydroergotamine • not approved • ?dose – 0.1 – 0.5 mg IV • not studied in emergency population • Linder SL – Treatment of childhood migraine with dihydroergotamine mesylate Headache - 1994 Nov-Dec; 34(10): 578-80 • N = 30 • inpatient protocol • IV DHE and PO metoclopramide – average 5 doses! • 80% response

47. phenothiazines • again no studies • metoclopramide 1-2 mg/kg IV (max 10mg) • prochloperazine 0.1 – 0.15 mg/kg IV/IM/PO/PR (max 10mg) • children may be more susceptible to EPS • ? pre-treat with benadryl

48. triptans • mostly studied in adolescent groups • sumitriptan subcutaneous 0.06mg/kg • Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50 consecutive patients with acute migraine in a pediatric neurology office practice. Headache 36:419–422, 1996 • N = 50 age 6-18 • 78% effective at 2 hours • 6% recurrence • sumitriptan intranasal • long term treatment studies done • no emergent studies • triptans PO • studies plagued by high placebo response

49. chronic progressive headache • least common presentation • most worrisome for increased ICP • pseudotumor cerebri • space occupying lesion

50. imaging indications? discuss • lack of evidence to help • small studies lack power to guide decision making • MRI preferred in non-urgent indication