pediatric seizure and status epilepticus management in the emergency setting l.
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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting Edward P. Sloan, MD, MPH Associate Professor & Research Development Director Dept of Emergency Medicine University of Illinois College of Medicine Chicago, IL Attending Physician Emergency Medicine

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Pediatric Seizure and Status Epilepticus Management in the Emergency Setting

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edward p sloan md mph associate professor research development director dept of emergency medicine

Edward P. Sloan, MD, MPHAssociate Professor & Research Development DirectorDept of Emergency Medicine

University of Illinois College of Medicine

Chicago, IL

attending physician emergency medicine

Attending Physician Emergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection

Medical Center

pediatric seizures se clinical case
Pediatric Seizures & SEClinical Case
  • A 13 year old female presents with a frontal HA and prior migraines that are relieved with ibuprofen
  • She had some AMS in the AM, with unusual motor activity (restless, thrashing on bed)
  • She had no other systemic sx, recent illness, or head trauma
  • She presented with normal vital signs and normal neurologic exam
  • What should the emergency physician do?
  • What is the expected outcome of this patient?
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 session objectives
OverviewSession Objectives
  • Review main peds sz types, etiologies
  • Briefly discuss Rx based on sz type
  • Discuss relevant ED peds sz cases
  • Summarize what Rx options exist
  • Discuss rational treatment decisions
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 epidemiology8
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 dvlp epilepsy
  • SE most common before age 1
overview pediatric se epidemiology
OverviewPediatric SE 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
pediatric sz etiologies hyponatremia
Pediatric Sz EtiologiesHyponatremia
  • Causes long duration szs and SE
  • Infants < 6 months old, no clear etiol
  • Too much water in formula
  • Hypothermia (Temp < 36.5 degrees)
pediatric sz etiologies cocaine toxicity
Pediatric Sz EtiologiesCocaine 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 mvmts
  • 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 generalized tonic clonic sz
Specific Seizure Types Generalized Tonic-Clonic Sz
  • Seizure described as a convulsion
  • May occur primarily or secondarily
  • May be preceded by prodrome or aura
  • Tonic, then clonic phase
  • Tongue biting, urinary incontinence
  • Last for minutes, then post-ictal
specific seizure types absence seizure
Specific Seizure Types Absence Seizure
  • Petit mal epilepsy
  • Brief, limited motor activity
  • Sudden interruption of consciousness
  • Slight clonic mvmts, myoclonic jerks
  • Automatisms also can be seen
  • Last about 10 sec, not post-ictal
specific seizure types partial seizure
Specific Seizure Types Partial Seizure
  • Focal motor sz (Jacksonian, frontal)
  • Focus and/or lesion in cerebrum
  • Sz clearly related to a lesion
  • Sz type related to site of sz focus
  • CT scan is useful
  • Simple partial sz pts have no AMS
specific seizure types complex partial seizure
Specific Seizure Types Complex Partial Seizure
  • Psychomotor, temporal lobe epilepsy
  • Often a history of febrile seizures
  • Complex aura, altered behavior
  • Automatisms: lip smacking, chewing
  • Not complete LOC, instead confused
  • May secondarily generalize
specific seizure types neonatal seizure
Specific Seizure Types Neonatal Seizure
  • Occur in first 28 days of life
  • Most occur shortly after birth
  • Subtle sz: lip smack, eye mvmt, apnea
  • Perinatal asphyxia, metabolic abn
  • Hypoglycemia, hypocalcemia
  • CNS infection, hemorrhage, lesion
specific seizure types benign childhood epilepsy
Specific Seizure Types Benign Childhood Epilepsy
  • Rolandic epilepsy
  • Onset between 3 and 13 years of age
  • Often occurs upon awakening
  • Facial mvmts, grimacing, vocalizations
  • EEG diagnosis
specific seizure types infantile spasms
Specific Seizure Types Infantile Spasms
  • West syndrome
  • Occurs up to one year
  • May be symptomatic or idiopathic
  • Sudden tonic movements of the head, trunk, extremities
  • Must do full work-up, incl metabolic
  • Caution, AED hepatotoxicity a risk
specific seizure types lennox gastaut syndrome
Specific Seizure Types Lennox-Gastaut Syndrome
  • Onset from 1-8 years
  • Peaks at 3-5 years
  • Multiple seizure types
  • GTC, tonic, absence, atonic szs
  • ED Hx: exac of known sz disorder
specific seizure types atonic seizures
Specific Seizure Types Atonic Seizures
  • Astatic or akinetic seizures
  • Sudden loss of motor tone
  • Child falls to the floor
  • May have myoclonic jerks
  • No clear generalized seizure
  • No etiology of apparent syncopal episode
specific seizure types febrile seizures
Specific Seizure Types Febrile 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 Types Juvenile 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 se types generalized convulsive se
Specific SE Types Generalized 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 se types non convulsive se
Specific SE 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
specific se types subtle se
Specific SE Types Subtle SE
  • Late manifestation of GCSE, frank coma
  • No longer with tonic-clonic mvmts
  • Still actively seizing (electrical SE)
  • Usu in older patients
  • Marked co-morbidity (encephalopathic)
  • Highest SE mortality
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
  • Myoclonic: Valproate, clonazepam
  • Partial: Carbamazepine, phenytoin, valproate
  • Generalized: Carbamazepine, phenytoin, phenobarb, primidone, valproate
case presentations ed pediatric seizure cases
Case PresentationsED Pediatric Seizure Cases
  • Pediatric complex partial SE
  • New onset SE in an adolescent
  • New onset sz in a college student
pediatric se pediatric complex partial se
Pediatric SE: Pediatric Complex Partial SE
  • How do we Dx complex partial SE?
  • What is the optimal Rx protocol?
  • Why?
pediatric se hx
Pediatric SEHx
  • 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 con t
Pediatric SEHx (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…”
pediatric se px
Pediatric SEPx
  • 98.7 98/60 72 20
  • Well hydrated
  • CV, lung exams normal
  • Neuro exam intact
pediatric se clinical course
Pediatric SEClinical 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 con t
Pediatric SEClinical Course (con’t)
  • Three more episodes over 40’
  • Similar autonomic symptoms
  • Some non-purposeful ext mvmts
  • Diaphoresis, urinary incontinence
  • Remained somnolent between episodes
pediatric se dx
Pediatric SEDx
  • Repetitive episodes with AMS
  • Autonomic symptoms noted
  • Non-purposeful mvmts noted
  • Rule out complex partial status epilepticus (CPSE)
pediatric se rx
Pediatric SERx
  • IV lorazepam
  • IV valproate
  • Transfer to Children’s
  • ICU observation
  • Uncomplicated course
adolescent se new onset ams spells
Adolescent SE: New Onset AMS/Spells
  • What is the AMS?
  • Is it a seizure?
  • How should we Rx new onset szs?
  • What is the role of the ED EEG?
  • When should it be ordered?
adolescent se hx
Adolescent SEHx
  • 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 SEPx
  • Vitals OK, afebrile
  • Alert, O x 3, NAD
  • Head/Neck OK
  • Chest/cor/abd OK
  • Neuro: No focal deficit. MS OK
adolescent se question 1
Adolescent SEQuestion # 1
  • What diagnostic tests are indicated at this point?
adolescent se question 2
Adolescent SEQuestion # 2
  • Did the patient have a seizure?
  • Does it influence Dx, Rx?
adolescent se question 3
Adolescent SEQuestion # 3
  • Does the patient require admission for observation for possible new onset seizures?
adolescent se clinical course
Adolescent SEClinical 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 question 4
Adolescent SEQuestion # 4
  • Is this repeat spell a seizure?
  • What type?
adolescent se question 5
Adolescent SEQuestion # 5
  • Does this AMS and motor activity require Rx?
  • What Rx?
adolescent se question 6
Adolescent SEQuestion # 6
  • Does the patient now require admission for observation for possible new onset seizures?
adolescent se clinical course con t
Adolescent SEClinical Course (con’t)
  • During EEG, pt with R face focal sz
  • Leftward gaze noted
  • Seizure then generalized
  • Meds were given
  • Seizure terminated
adolescent se question 7
Adolescent SEQuestion # 7
  • What med is to be used for seizure control / SE termination?
adolescent se question 8
Adolescent SEQuestion # 8
  • What med is to be used once SE is terminated?
  • Why?
adolescent se question 9
Adolescent SEQuestion # 9
  • How should the meds be given?
  • Why?
adolescent se clinical course con t59
Adolescent SEClinical Course (con’t)
  • SE 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 SEDx
  • New onset SE
  • Complex partial seizures with generalized seizure / SE
  • Hx migraine headaches
adolescent se rx
Adolescent SERx
  • Lorazepam to Rx the acute sz
    • 2mg IVP x 2
  • Valproate for ongoing protection
    • 25 mg/kg load administered
    • Infused over 20 minutes
  • PRN meds during transfer
juvenile myoclonic sz college student new onset sz
Juvenile Myoclonic Sz: College Student, New Onset Sz
  • What is the likely etiology?
  • What is JME?
  • What are the long-term implications?
  • How to RX once the sz terminated?
juvenile myoclonic sz hx
Juvenile Myoclonic SzHx
  • 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 SzPx
  • Vitals OK
  • Neuro: slightly post-ictal
  • Exam otherwise normal
  • Patient has a 2nd seizure in the ED
juvenile myoclonic sz dx
Juvenile Myoclonic SzDx
  • 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 SzRx
  • 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
ConclusionsClinical 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
recommendations management implications
RecommendationsManagement 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