Challenging Pediatric Seizure and SE 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 levitiracetam, 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? • AMS, no seizure disorder • Complex partial status epilepticus (CPSE) with autonomic signs • Generalized non-convulsive seizure with autonomic signs • Generalized convulsive SE
Case #2Dx • Repetitive episodes with AMS • Rule out generalized nonconvulsive status epilepticus • Rule out complex partial status epilepticus • Associated autonomic signs
Case #2Rx How would you initially treat this pediatric seizure patient? • IV diazepam • IV lorazepam • IV phenobarbital • IV valproate • Other
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 • Valproate is likely the drug of choice • Phenytoin may not be optimal • Avoid status epilepticus
Case #5:New Onset AMS/Spells • What is the AMS? • Is it a seizure? • How should we Rx new onset szs? • What role does the E.D. 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?