Emergency Department Admission of Children With Unprovoked Seizure: Recurrence within 24 Hours

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Emergency Department Admission of Children With
Unprovoked Seizure Recurrence within 24 Hours

• Pediatric Neurology
• 2006 Vol.35 No.2
• By Hu mei-hua

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Introduction-1

• Seizure is one of the common reason for emergency
  department visits, especially if the seizure is
  of new onset or the child is not on antiepileptic
  medication.
• Approximately 4 to 6 of children will have a
  seizure by 16 years of age.
• Fleisher GR, Ludwig S, eds. Textbook of pediatric
  emergency medicine, 4th ed. Philadelphia
  Lippincott, Williams Wilkins, 2000573-9.
• The criteria for admission in these children are
  not clear.

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Introduction-2

• Admission of seizure patients is often based on
• known risk factors of epilepsy, such as
  symptomatic etiology and history of previous
  seizure.
• The purpose of this study is twofold
• (1) to define the clinical profile of seizure
  patients who are likely to be admitted for
  observation or treatment.
• (2) to analyze the incidence, and the risk
  factors of acute recurrence of seizures in the
  admitted children within 24 hours after admission.

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Materials and Methods-1

• A retrospective, emergency department chart
  review of all pediatric patients (age under 21
  years) who arrived at the Schneider Childrens
  Hospital Emergency Department because of an
  unprovoked seizure during the year 2001 was
  conducted.
• The study excluded children who were on
  antiepileptic medications.
• Inpatient charts were also reviewed

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Materials and Methods-2

• SC Hospital is a 154-bed childrens hospital with
  an annual emergency department census of 25,000
  patient visits.
• Patients were identified using the ICD-9 as part
  of their emergency department or final hospital
  discharge diagnosis.
• The study was exempted from the IRB.

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Materials and Methods-3

• The clinical profile of these admitted children
  included
• Diagnosis (epilepsy, new-onset seizure),
• Etiology (symptomatic, idiopathic),
• Age,
• Duration (less than 5 minutes, longer than 5
  minutes),
• Multiple seizuresbefore emergency department
  arrival (more than one seizure in 24 hours),
• Emergency department (ED) treatment.

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Materials and Methods-4

• History of pervasive developmental disorder and
  global developmental delay were considered
  symptomatic etiology.
• The history of ADHD and isolated speech delay
  were considered idiopathic etiology.
• In those children who were admitted, the rate of
  acute seizure recurrence was evaluated and
  correlated with potential risk factors such as
  diagnosis, etiology, age, duration of seizure,
  multiple seizures before ED, ED treatment, and
  EEG results.

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Materials and Methods-5

• A comparison of two groups
• admitted children vs discharged children,
• inpatients with acute recurrence vs inpatients
  without acute recurrence
• ( chi-square or an unpaired t test analysis)
• Statistical significance was established at P
  0.05.

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Results-1

• Total 117 (M F6948)
• mean age 6 years and 8 months old
• 59 admitted
• The mean age
• Admission ? 3 years and 8 months (2 m/o to 18
  y/o)
• Discharge? 8 y/o (9 m/o to 20 y/o)

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Results - 2

• Children with multiple seizures before arrival to
  the ER were more likely to be admitted than those
  with single seizure (P 0.001).
• Children who received antiepileptic medication in
  ER were more likely to be admitted (P 0.001).
• 16 children received lorazepam,
• 4 children received lorazepam and phenytoin,
• 1 child received lorazepam and phenobarbital,
• 1 child received diazepam.
• 86 of 117 children (73.5) had CT scan in the
  hospital, not necessarily in ER.

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Results - 3

• Admitted CT 81.2 (56 of 67)? normal in 41 and
  abnormal in 15 (26.7).
• Discharged CT 62.5 (30 of 48) ? normal in 27
  and abnormal in 3 (10).
• The results of CT scans were not analyzed, as we
  could not determine if the decision of admission
  was made before or after the CT result.

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Sharma S, Riviello
JJ, Harper MB, Baskin MN.
The role of emergency neuroimaging in
children
with new-onset afebrile seizures. Pediatrics
20031111-5.
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Results - 4

• Seizure recurrence within 24 hours 14 (20)
  children
• Multiple seizures before ER arrival was the only
  significant risk factor that correlated with
  recurrence of seizure within 24 hrs.
• EEG ? 85.5 children (normal abnormal3326)
• Neither abnormal EEG nor epileptiform EEG were
  correlated with recurrence of acute seizures.
• Treatment in the ER did not lower the acute
  recurrence rate.

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Discussion- 1

• 4 of all ER visits to our hospital were for
  children who had a seizure, which is similar to
  the previous report from the Boston Childrens
  Hospital 1.
• Sharma et al. suggested that emergent
  neuroimaging should be considered for the
  children with new-onset seizure, if they have
  conditions predisposing them to intracranial
  abnormalities, or if they were 33 months old with
  focal seizures.
• In other words, well-appearing children with
  new-onset afebrile seizure for whom these
  criteria do not apply can be safely discharged
  from the ER without neuroimaging if follow-up can
  be assured.

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Discussion- 2

• EEG be performed as part of the evaluation of a
  child with a first unprovoked seizure, although
  it does not influence the decision regarding
  treatment after a first seizure.
• It is becoming clear that admission in order to
  obtain the neuroimaging or EEG is not
  appropriate.

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Discussion- 3

• The main reasons in our hospital to admit
  children through the ED were
• (1) those children who have acute medical
  problems or have not returned to their baseline
  condition
• (2) those children who have higher risk of acute
  recurrence of seizures
• (3) those children whose follow-up can not be
  ensured.

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Discussion- 4

• Shinnar et al. have reported that the risk
  factors for seizure recurrence included
• a remote symptomatic etiology,
• an abnormal EEG,
• a seizure occurring while asleep,
• a history of prior febrile seizures,
• Todds paresis.

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Discussion- 5

• Our data confirmed that the ER physicians tend to
  admit children with multiple seizures, younger
  age, and children who received antiepileptic
  medication in the ED.
• The limitations of this study include its
  retrospective design as well as lack of follow-up
  of 48 children who were discharged from the ED.
• Clinical data were limited to what was available
  in the ED records, and some of the risk factors
  that Shinnar et al. 3 mentioned, such as Todds
  paresis and sleep status, were frequently not
  mentioned in the ED records.

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Discussion- 6

• It is possible that some of the discharged
  children had acute recurrent seizures at home.
• Prospective studies to better identify the risk
  factors of acute recurrence are warranted to
  develop management strategies for children who
  presented to the ED because of seizure.
• Future study should include the follow-up of
  discharged children and a focus to identify
  low-risk children who may be safely managed as
  outpatients.

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Thank you for your attention