the acep seizure clinical policy what about pediatric patients
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The ACEP Seizure Clinical Policy: What About Pediatric Patients. Andy S. Jagoda, MD. Professor and Vice Chair Residency Program Director Department of Emergency Medicine Mount Sinai School of Medicine New York, NY . Learning Objectives.

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andy s jagoda md
Andy S. Jagoda, MD

Professor and Vice ChairResidency Program DirectorDepartment of Emergency MedicineMount Sinai School of MedicineNew York, NY

learning objectives
Learning Objectives
  • Discuss the development of clinical policies and their relevance to ED clinical practice
  • Describe the recommended treatment strategies of pediatric ED seizures and status epilepticus
  • Present seizure patient scenarios that will allow help clinical decision making in caring for the pediatric seizure patient
ann emerg med 2004 43 605
Ann Emerg Med 2004;43:605

Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures

Not a comprehensive manual

No substitute for clinician’s judgment

why are clinical policies being written
Why are Clinical Policies being Written?
  • Differentiate “evidence based” practice from “opinion based”
    • Clinical decision making
    • Education
    • Reducing the risk of legal liability for negligence
  • Improve quality of health care
    • Assist in diagnostic and therapeutic management
  • Improve resource utilization
    • May decrease or increase costs
  • Identify areas in need of research
interpreting the literature
Interpreting the Literature
  • Terminology
    • Status epilepticus
  • Patient population
    • Children vs adults
  • Interventions / outcomes
    • Termination of motor activity vs termination of electrical activity
description of the process
Description of the Process
  • Medical literature search
  • Secondary search of references
  • Articles graded
  • Recommendations based on strength of evidence
  • Multi-specialty and peer review
description of the process8
Description of the Process

Strength of evidence (Class of evidence)

  • I: Randomized, double blind interventional studies for therapeutic effectiveness; prospective cohort for diagnostic testing or prognosis
  • II: Retrospective cohorts, case control studies, cross-sectional studies
  • III: Observational reports; consensus reports

Strength of evidence can be downgraded based on methodologic flaws

case studies lab testing
Case Studies: Lab Testing

Case #1: 12 yo healthy boy has a witnessed tonic clonic seizure that lasts 30 seconds followed by a half hour post ictal period; he is alert with a normal neurologic exam in the ED.

Case #2: A 2 yo healthy infant rapidly develops a fever of 39 and has a witnessed tonic clonic seizure lasting 2 minutes. In the ED he is alert with a normal exam.

lab testing
Lab Testing
  • What laboratory tests are indicated in the otherwise healthy pediatric patient with a new-onset seizure who has returned to a baseline normal neurological status?
  • What about pediatric patients with febrile seizures?
acep clinical policy lab testing
ACEP Clinical Policy: Lab Testing
  • Level A recommendations – None
  • Level B recommendations
      • Determine a serum glucose and sodium level on patients with first-time seizure with no comorbidities who have returned to their baseline.
      • Obtain a pregnancy test if a woman is of child-bearing age.
acep clinical policy lab testing12
ACEP Clinical Policy: Lab Testing
  • The policy suggests that a serum glucose and sodium determinations are appropriate in Case #1.
  • The policy discusses the role of toxicologic screens but due to lack of evidence is unable to make any specific recommendations
lab testing case 1
Lab Testing: Case #1
  • The patient and friends are suspected of experimenting with cocaine
  • Toxicologic analysis confirmed the presence of cocaine metabolites
  • The patient in Case #1 is diagnosed with a drug related seizure:
    • Does he need a neuroimaging study?
    • Does he need an EEG?
    • Should he be treated with an AED?
lab test case 2
Lab Test: Case #2
  • The patient meets the criteria for a simple febrile seizure
    • 6 mo – 5 years
    • Nonfocal, generalized seizure
    • Related to rapid onset fever
    • Last < 15 minutes
  • Adults do not get simple febrile seizures
evaluating a first nonfebrile seizure in children neurology 2000 55 616 623
Evaluating a first nonfebrile seizure in children. Neurology 2000; 55:616-623
  • Laboratory tests:
    • Laboratory tests should be ordered based on individual clinical circumstances that include suggestive historic or chinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness (option)
      • Glucose and sodium low yeild but high value
    • Toxicology screening should be considered across the entire pediatric age range if there is any question of drug exposure or substance abuse (option)
slide16
The neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics 1996; 97:769-775.
  • Blood studies:
    • Blood studies (electrolytes, calcium, phosphate, magnesium, CBC, blood glucose) are not recommended routinely in the evaluation of a child with a first simple febrile seizure
the neurodiagnostic evaluation of a first simple febrile seizure pediatrics 1996 97 769 775
The neurodiagnostic evaluation of a first simple febrile seizure. Pediatrics 1996; 97:769-775.
  • Lumbar puncture:
    • Strongly considered in infants younger than 12 months and infants and children who have received prior antibiotics
    • Considered in children 12 – 18 months although a LP is not routinely warrented
    • Not routinely warrented in children > 18 months
case studies neuroimaging
Case Studies: Neuroimaging

Case #1: 12 yo healthy boy has a witnessed tonic clonic seizure that lasts 30 seconds followed by a half hour post ictal period; he is alert with a normal neurologic exam in the ED.

Case #2: A 2 yo healthy infant with a URI develops a fever of 39 and has a witnessed tonic clonic seizure lasting 60 seconds. In the ED he is alert with a normal exam.

neuroimaging
Neuroimaging
  • Which new-onset pediatric seizure patients who have returned to a normal baseline require a head CT in the ED?
  • Focal neurologic findings and / or history of trauma or CNS disorder increase incidence of pathologic findings
acep clinical policy neuroimaging
ACEP Clinical Policy: Neuroimaging
  • Level A recommendations - None
  • Level B recommendations
      • When feasible, perform neuroimaging of the brain in the ED on patients with a first-time seizure.
      • Deferred outpatient neuroimaging may be used when reliable follow-up is available.
acep clinical policy neuroimaging21
ACEP Clinical Policy: Neuroimaging
  • The ACEP Clinical Policy suggests that imaging may be deferred in Case #1
  • CTs rarely change immediate management in the patient with a normal neuro exam but have significant impact on disposition and on initiation of AED treatment
  • Risk of ioning radiation in children is an important concern
evaluating a first nonfebrile seizure in children neurology 2000 55 616 62322
Evaluating a first nonfebrile seizure in children. Neurology 2000; 55:616-623
  • Neuroimaging
    • If a neuroimaging study is obtained, MRI is the preferred modality (guideline)
    • Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit not quickly resolving, or who has not returned to baseline within several hours after the seizure (option)
acep clinical policy eeg
ACEP Clinical Policy: EEG
  • When should EEG testing be performed in the ED?
  • Level C: Consider an emergent EEG in patients suspected of being in nonconvulsive status epilepticus or in subtle convulsive status epilepticus, patients who have received a long-acting paralytic, or patients who are in drug-induced coma.
evaluating a first nonfebrile seizure in children neurology 2000 55 616 62324
Evaluating a first nonfebrile seizure in children. Neurology 2000; 55:616-623
  • EEG
    • The EEG is recommended as part of the neurodiagnostic evaluation of the child with an apparent first unprovoked seizure (standard)* *

* * Timing of EEG is not specified

acep clinical policy disposition and treatment
ACEP Clinical Policy: Disposition and Treatment
  • Case #1: 12 yo healthy boy has a tonic clonic sz that lasts 30 seconds followed by a half hour post ictal period; he is alert with a normal neurologic exam in the ED.
  • Lab tests are normal. EEG / MRI pending
    • Would you admit this patient?
    • Would you start this patient on an AED?
acep clinical policy disposition and treatment26
ACEP Clinical Policy: Disposition and Treatment
  • Level A / B recommendations - None
  • Level C recommendations
      • Patients with a normal neurologic examination can be discharged from the ED with outpatient follow-up.
      • Patients with a normal neurologic examination, no comorbidities, and no known structural brain disease do not need to be started on an antiepileptic drug in the ED.
treatment of the child with a first unprovoked seizure neurology 2003 60 166 175
Treatment of the child with a first unprovoked seizure. Neurology 2003: 60:166-175
  • Historically children were started on an AED after a first unprovoked seizure:
    • Attempt to prevent “kindling” thus development of epilepsy
    • Prevent risk of injury
treatment of the child with a first unprovoked seizure neurology 2003 60 166 17528
Treatment of the child with a first unprovoked seizure. Neurology 2003: 60:166-175
  • Seizure recurrence after first unprovoked seizure 20% - 50%
  • Abnormal EEG and / or neuroimaging increases risk of seizure recurrence
  • Availability of testing and follow-up determines need for admission
treatment of the child with a first unprovoked seizure neurology 2003 60 166 17529
Treatment of the child with a first unprovoked seizure. Neurology 2003: 60:166-175
  • Treatment with AED is not indicated for the prevention of the development of epilepsy (level B)
  • Treatment with AED may be considered in circumstances where the benefits of reducing the risk of a second seizure outweigh the risks of pharmacologic and psychosocial side effects (level B)
acep clinical policy phenytoin dosing strategies
ACEP Clinical Policy: Phenytoin Dosing Strategies
  • What are effective phenytoin or fosphenytoin dosing strategies for preventing seizure recurrence in patient who present to the ED after having had a seizure with a subtherapeutic serum phenytoin level?
  • Limited applicability to pediatric population since other AEDs have less side effects and better tolerability
acep clinical policy phenytoin dosing strategies31
ACEP Clinical Policy: Phenytoin Dosing Strategies
  • Level C recommendation: Administer an intravenous or oral loading dose of phenytoin or intravenous or intramuscular fosphenytoin, and restart daily oral maintenance dosing.
acep clinical policy status epilepticus
ACEP Clinical Policy: Status Epilepticus
  • The 12 yo boy in Case #1 had a positive EEG and a MRI that demonstrated hippocampal scarring. A diagnosis of partial epilepsy with secondary generalization was made and he was started on valproic acid.
  • 6 months later he returns to the ED via EMS having had 3 generalized events without return to baseline
acep clinical policy status epilepticus33
ACEP Clinical Policy: Status Epilepticus
  • Upon arrival in the ED he has a fourth tonic clonic event that does not stop.
  • After the ABCs and blood sugar are addressed:
    • What is your first line AED?
    • What is your second line AED?
    • How do you manage refractory status epilepticus?
acep clinical policy status epilepticus34
ACEP Clinical Policy: Status Epilepticus
  • What agent(s) should be administered to a patient in status epilepticus who continues to seize after having received a benzodiazepine and a phenytoin?
  • Are there patients where phenytoin should not be used as a second line agent?
acep clinical policy status epilepticus35
ACEP Clinical Policy: Status Epilepticus
  • Level C: Administer 1 of the following agents intravenously
    • “high-dose phenytoin”
    • Phenobarbital
    • valproic acid
    • midazolam infusion
    • pentobarbital infusion
    • propofol infusion.
acep clinical policy status epilepticus36
ACEP Clinical Policy: Status Epilepticus
  • Though there are many opinions, no data exist to guide specific therapies.
  • It would seem reasonable to empirically administer valproate, particularly if levels are demonstrated to be low.
  • The new antiepileptic drugs pose a challenge since levels cannot be determined.
summary
Summary
  • Evidence based clinical policies are useful tools in clinical decision making
  • Clinical policies do not create a “standard of care” but do provide a foundation for clinical practice at a national level
  • The current literature on acute seizure management in children, as in adults, does not support the creation of “level A” recommendations and there is need for future research to help clarify many of our diagnostic and treatment strategies
questions
Questions??

[email protected] S. Jagoda, [email protected]

ferne_2005_aaem_france_jagoda_pedssz_fshow.ppt 8/29/2005 5:35 AM

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