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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting Edward P. Sloan, MD, MPH Associate Professor Department of Emergency Medicine University of Illinois Chicago, IL. Case.

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slide1

Pediatric Seizure and Status Epilepticus Management in the Emergency SettingEdward P. Sloan, MD, MPHAssociate ProfessorDepartment of Emergency MedicineUniversity of IllinoisChicago, IL

slide2
Case

A 7-year old boy presents to the ED with a history of staring spells, some shaking movements, and headache over the past day. He has no history of seizures or epilepsy. In the ED, he has three episodes of tachycardia, staring and confusion that last several minutes and resolve without therapy. He then has a similar episode associated with diaphoresis and urinary incontinence. His most likely diagnosis is:

most likely diagnosis
Most likely diagnosis:
  • Absence status epilepticus
  • Complex partial status epilepticus
  • Benign childhood epilepsy
  • Lennox-Gastaut syndrome
  • Generalized convulsive status epilepticus
slide5
Assuming that the above episodes in the 7-year

old represent repeated seizures, all of the

following are acceptable initial therapies except:

  • Rectal diazepam
  • Rectal diazepam gel
  • IM midazolam
  • IV lorazepam
  • IV phenobarbital
slide7
Case

A 13-year old female presents at mid-morning to the ED with a one-day history of a frontal headache, consistent with prior migraines, that was relieved with ibuprofen. She also was noted by family members to be restless in bed, and was noted to “thrash about for a brief period of time.” The family denied that this was a generalized seizure, and denied any history of epilepsy, trauma, drug ingestion, or similar episodes. The patient has a similar episode in the ED, and then has a generalized seizure.

most likely diagnosis1
Most likely diagnosis:
  • Primary generalized seizure
  • Absence seizure
  • Complex partial seizure with secondary generalization
  • Juvenile myclonic epilepsy
  • Non-convulsive status epilepticus
slide10
Case

A 21-year old male college student presents in the early morning to the ED with a one-day history of having a generalized seizure upon awakening. The patient had been partying after final exams, and had not been getting much sleep for several days. Over the phone, his mom noted that he had a history of “staring spells” as a child.

most likely diagnosis2
Most likely diagnosis:
  • Primary generalized seizure
  • Absence seizure
  • Complex partial seizure with secondary generalization
  • Juvenile myoclonic epilepsy
  • Non-convulsive status epilepticus
slide13
The above 21-year old patient had two seizures in the ED which were controlled with lorazepam. If a load of a longer acting AED was to be given in the ED in order to prevent status epilepticus, what would be the optimal drug to administer?
most optimal drug
Most optimal drug:
  • IV midazolam
  • IV phenytoin
  • IV fosphenytoin
  • IV valproate
  • IV phenobarbital
what is the optimal loading dose of iv valproate in patients at risk for se
What is the optimal loading dose of IV valproate in patients at risk for SE?
  • 1-5 mg/kg
  • 10-15 mg/kg
  • 20-30 mg/kg
  • 90-100 mg/kg
slide18
If an IV valproate load of 25 mg/kg were given to this patient, what would be the expected valproate level once the infusion had ended?
expected iv valproate level
Expected IV Valproate level?
  • 25 mg/L
  • 50 mg/L
  • 75 mg/L
  • 100 mg/L
  • 125 mg/L
slide21
If this patient were to develop status epilepticus, what is the fastest time of infusion possible for a loading valproate infusion of 2500 mg (25 mg/kg x 100 kg)?
fastest infusion time possible
Fastest Infusion Time Possible?

Fastest Infusion Time Possible?

  • 4 minutes (6 mg/kg/minute)
  • 8 minutes (3 mg/kg/minute)
  • 24 minutes (1 mg/kg/minute)
  • 2 minutes (0.3 mg/kg/minute)
  • 216 minutes (0.1 mg/kg/minute)
overview global objectives
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
overview pediatric sz epidemiology
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%)
overview pediatric sz epidemiology1
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 develop epilepsy
  • SE most common before age 1
overview pediatric sz epidemiology2
OverviewPediatric Sz 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
pediatric sz etiologies meningitis
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
hyponatremia
Hyponatremia
  • Causes long duration szs and SE
  • Infants < 6 months old, no clear etiol
  • Too much water in formula
  • Hypothermia (Temp < 36.5 degrees)
cocaine toxicity
Cocaine Toxicity
  • Consider in new onset seizures
  • Crack cocaine rocks ingested
  • Especially when no other etiology
  • Common in urban EDs
pediatric seizures seizure outcome
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%)
pediatric seizures se outcome
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
pediatric seizures seizure type classification
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
seizure classification generalized seizures
Seizure ClassificationGeneralized Seizures
  • Convulsive seizures
    • Tonic sz: sustained contractions
    • Clonic sz: rhythmic flexor spasms
    • Tonic-clonic sz: combined movements
  • Non-convulsive
    • Simple absence: impaired consciousness
    • Complex absence: brief motor mvmts
seizure classification partial seizures
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
pediatric seizures other generalized sz types
Pediatric SeizuresOther Generalized Sz Types
  • Neonatal seizures
  • Benign childhood epilepsy (Rolandic)
  • Infantile spasms (West syndrome)
  • Lennox-Gastaut syndrome
  • Atonic seizures
  • Febrile seizures
pediatric seizures status epilepticus types
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
specific seizure types febrile seizures
Specific Seizure TypesFebrile 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
specific seizure types juvenile myoclonic epilepsy
Specific Seizure TypesJuvenile 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
specific seizure types generalized convulsive se
Specific Seizure TypesGeneralized 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
specific seizure types non convulsive se
Specific Seizure 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
seizure therapy generalized seizure protocol
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
seizure therapy ongoing therapies
Seizure Therapy Ongoing Therapies
  • Absence: ethosuximide, valproate
  • Atonic: valproate, clonazepam,

ethosuximide

  • Myclonic: valproate, clonazepam
  • Partial: carbamazepine,

phenytoin, valproate

  • Generalized: carbamazepine,

phenytoin, phenobarb,

primidone, valproate

case presentation ed pediatric seizure cases
Case PresentationED Pediatric Seizure Cases
  • Pediatric complex partial SE
  • New onset SE in an adolescent
  • New onset sz in a college student
pediatric se hx
Pediatric SE Hx
  • 7 year old male
  • Seizure-like activity?
  • Patient with staring spells
  • Some headache and shaking movement, esp of hands
  • Frontal headache, vomiting
pediatric se hx cont
Pediatric SE Hx (cont.)
  • 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…”
pediatric se px
Pediatric SE Px
  • 98.7, 98/60 72 20
  • Well-hydrated
  • CV, lung exams normal
  • Neuro exam intact
pediatric se clinical course
Pediatric SE Clinical Course
  • 0220 “episode”
  • Tachycardia, BP OK, airway OK
  • Confused, staring off into space
  • Episode lasted < 5 minutes
  • Resolved without any Rx
pediatric se clinical course cont
Pediatric SE Clinical Course (cont.)
  • Three more episodes over 40’
  • Similar autonomic symptoms
  • Some non-purposeful ext mvmts
  • Diaphoresis, urinary incontinence
  • Remained somnolent between episodes
pediatric se dx
Pediatric SE Dx
  • Repetitive episodes with AMS
  • Autonomic symptoms noted
  • Non-purposeful mvmts noted
  • Rule out complex partial status epilepticus (CPSE)
pediatric se rx
Pediatric SE Rx
  • IV lorazepam
  • IV valproate
  • Transfer to Children’s
  • ICU observation
  • Uncomplicated course
adolescent se hx
Adolescent SE Hx
  • 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
adolescent se px
Adolescent SE Px
  • Vitals OK, afebrile
  • Alert, O x 3, NAD
  • Head/Neck OK
  • Chest/cor/abd OK
  • Neuro: No focal deficit. MS OK
adolescent se clinical course
Adolescent SE Clinical Course
  • Labs, tox screen neg
  • CT negative
  • Neuro consult: EEG and then D/C
  • Dx: AMS, r/o Seizure; migraine HA
  • While EEG applied, pt with AMS
  • Agitation, thrashing on cart
adolescent se clinical course cont
Adolescent SE Clinical Course (cont.)
  • During EEG, pt with R face focal sz
  • Leftward gaze noted
  • Seizure then generalized
  • Meds were given
  • Seizure terminated
adolescent se clinical course cont1
Adolescent SE Clinical Course (cont.)
  • Seizure terminated with Rx
  • Pt stabilized, still somnulent
  • ALS transfer team to Children’s
  • Pt with resolving AMS at time of D.C
adolescent se dx
Adolescent SE Dx
  • New onset SE
  • Complex partial seizures with generalized seizure / SE
  • Hx migraine headaches
adolescent se rx
Adolescent SE Rx
  • Lorazepam to Rx the acute sz
    • 2 mg IVP x 2
  • Valproate for ongoing protection
    • 25 mg/kg load administered
    • Infused over 20 minutes
  • PRN meds during transfer
juvenile myoclonic sz hx
Juvenile Myoclonic Sz Hx
  • 21 year old college student
  • No prior neuro history
  • Final exams, sleepless
  • Great party after the last exam
  • Pt with single generalized sz
  • Seizure upon awakening
juvenile myoclonic sz px
Juvenile Myoclonic Sz Px
  • Vitals OK
  • Neuro: slightly post-ictal
  • Exam otherwise normal
  • Patient has a 2nd seizure in the ED
juvenile myoclonic sz dx
Juvenile Myoclonic Sz Dx
  • Juvenile myoclonic epilepsy
  • Related to sleep deprivation, alcohol consumption
  • Occurs upon awakening
  • Responds best to valproate
  • Phenytoin may exacerbate sx
juvenile myoclonic sz rx
Juvenile Myoclonic Sz Rx
  • 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
conclusions clinical pearls
Conclusions Clinical Pearls
  • Acute, repetitive spells = sz
  • Ongoing altered mental status = complex partial SE
  • Treat acute szs with lorazepam
  • Valproate is the etiology-specific ongoing Rx in many young people
  • Know the specific JME clinical setting
conclusions learning points
Conclusions Learning Points
  • Acute, repetitive spells = sz
  • Multiple meds and routes possible
  • Opportunity to optimize Rx
  • Acute seizure control: IV benzos
  • 2nd line Rx may differ based on Dx
  • Ongoing needs may influence 2nd Rx
  • EEG may be of use in ED SE
recommendations management implications
Recommendations Management Implications
  • Educate about sz etiologies
  • Make multiple drugs available
  • Alternate routes should be used
  • A protocol should exist
  • Utilize EEG when necessary
  • Be aware of optimal Rx at disposition