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pediatric neurologic emergencies

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febrile seizure diazepam, phenobarbital, valproic acid. Currently AAP does not recommend ... phenobarbital. generalized TC phenytoin, phenobarbital, ... – PowerPoint PPT presentation

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Title: pediatric neurologic emergencies


1
pediatric neurologic emergencies
  • may 2002 core rounds

2
contents
  • seizures
  • approaches to
  • febrile seizure
  • new onset non-febrile seizure
  • established seizure disorder with recurrence
  • neonatal seizures
  • status epilepticus
  • investigation, treatment, disposition
  • headache
  • discussion (as little evidence to support)
  • migraine treatment
  • imaging indications

3
case 1
  • 2 year old
  • parents shaking episode lasting 10 mins
  • EMS called - child no longer shaking
  • V/S - BP 105/60 HR 100 RR 18 Sat N T39
  • approach?
  • well looking child
  • first event
  • multiple events
  • sick looking child

4
case 2
  • 8 year old
  • parents describe good history for tonic-clonic
    activity lasting 2 mins
  • 1st event
  • post event confusion - improving
  • in ED - V/S N, N sensorium, N neuro exam
  • otherwise healthy, no meds, no allergies
  • approach?

5
case 3
  • 16 year old
  • known seizure disorder, on phenytoin
  • typical seizure presenting complaint
  • V/S N, neuro N, otherwise looks well
  • approach?

6
case 4
  • 2 week old
  • parents - doesnt look right, mouth opening
    and closing
  • one episode lasting 1 minute
  • child not interested in feeding, sleepy
  • V/S - BP 90/50 HR 130 RR 38 sat N T 37.8
  • otherwise normal exam
  • approach?

7
definitions
  • febrile seizure NIH defn - event of
    infancy/childhood, typically between age 3mo and
    5yrs, with no evidence intracranial infection or
    defined cause
  • epilepsy - two or more seizures not provoked by a
    specific event such as fever, trauma, infection,
    or chemical change

8
definitions
  • neonatal seizure in first 28 days of life
    (typically first few days)
  • status epilepticus
  • seizure lasting gt30 mins
  • NB rosen 5-10 mins
  • sequential seizures without regain LOC gt30min

9
classification
  • generalized
  • LOC
  • tonic, clonic, tonic-clonic, myoclonic, atonic,
    absence
  • partial focal onset
  • simple partial no LOC
  • complex partial LOC
  • partial secondarily generalized
  • unclassified

10
etiology
  • infectious
  • metabolic
  • traumatic
  • toxic
  • neoplastic
  • epileptic
  • other

11
differential diagnosis
  • syncope
  • breath holding
  • sleep disorders (eg. narcolepsy)
  • paroxysmal movement disorder
  • tics,tremors
  • migraines
  • psychogenic seizures

12
approach to febrile seizures the numbers
  • epidemiology
  • age 3mo 5yrs
  • peak age 9-20 mo
  • 2-5 children will have before age 5
  • 25-40 will have family history
  • 80 97 simple
  • 3 - 20 complex

13
simple febrile seizure
  • lt 15 mins
  • no focal features
  • no greater than 1 episode in 24h
  • neurologically and developmentally normal

14
complex febrile seizure
  • gt15 min
  • febrile epilepticus gt30min or recurrent without
    regaining consciousness gt 30min
  • focal
  • recurrence within 24h

15
what do parents want to know?
  • recurrence
  • risk recurrence 25-50
  • risk recurrence after 2nd 50
  • most recurrences within 6-12 mo
  • (20 within same febrile illness)
  • risk of epilepsy
  • 2-3 (baseline 1)
  • increased in
  • family history of epilepsy
  • abnormal developmental status
  • complex febrile seizure

16
neonatal seizure
  • brief and subtle
  • eye blinking
  • mouth/tongue movements
  • bicycling motion to limbs
  • typically szs cant be provoked/consoled
  • autonomic changes
  • EEG less predictable

17
neonatal seizure
  • etiology
  • hypoxic-ischemic encephalopathy
  • Presents within first day
  • congenital CNS anomalies
  • intracranial hemorrhage
  • electrolyte abnormalities hypoglycemia and
    hypocalcemia
  • infections
  • drug withdrawal
  • pyrodoxine deficiency

18
status epilepticus
  • definition
  • deizure lasting gt30 mins
  • NB Rosen 5-10 mins
  • sequential seizures without regain LOC gt30min
  • mortality in pediatric status epilepticus 4
  • morbidity may be as high as 30

19
SE treatment considerations
  • ABCs
  • brief directed Hx and Px
  • glucose
  • antibiotics/antivirals
  • if meningitis/encephalitis considered

20
SE treatment
  • 1st line anticonvulsants
  • IV
  • lorazepam 0.1mg/kg
  • diazepam 0.2 mg/kg
  • midazolam 0.2 mg/kg
  • rectal diazepam
  • 2-5 yrs 0.5 mg/kg
  • 6-11 yrs 0.3 mg/kg
  • gt12 yrs 0.2 mg/kg
  • IM, intranasal, buccal midazolam

21
SE treatment
  • 2nd line agents
  • phenytoin 20 mg/kg _at_ 1mg/kg/min (upto 50 mg/min)
  • fosphenytoin 15-20 PE/kg _at_ 3 mg/kg/min (upto 150
    mg/min)
  • 3rd line agents
  • phenobarbital 20mg/kg _at_ 100mg/min
  • repeat prn 5-10mg/kg
  • maximum 40 mg/kg or 1 gram

22
refractory SE treatment
  • consider midazolam
  • 0.2 mg/kg bolus
  • then 1-10 mcg/kg/min infusion
  • induce barbiturate coma
  • pentobarbital 5-15 mg/kg _at_ 25 mg/min
  • then 1-5 mg/kg/hour
  • others
  • valproic acid
  • paraldehyde, chloral hydrate
  • propofol, inhalational anesthesia, paralysis
  • lidocaine

23
approach stable post sz
  • history
  • pre-seizure
  • what was child doing when attack occurred
  • precipitants fever, trauma, poisoning, drug/med
    use
  • aura
  • deizure
  • what movements incl. eyes
  • how long
  • LOC?
  • consequences resp distress, incontinence,
    injury
  • post seizure
  • Post-ictal

24
approach to stable patient
  • physical directed towards
  • systemic disease
  • infection
  • toxic exposure
  • focal neuro signs

25
laboratory
  • blood glucose?
  • electrolytes?
  • magnesium, calcium?
  • anything at all?
  • what about first time seizures? recurrent?

26
laboratory
  • yes if…
  • neonatal
  • abnormal mental status persistent
  • diabetics, renal disease
  • diuretic use
  • dehydration
  • malnourishment

27
laboratory
  • septic work-up (CBC, BC, urine CS, CXR, LP)
  • as indicated
  • sick child
  • lt 12 - 18 mo
  • therapeutic drug levels
  • other
  • ABG
  • toxicologic screen
  • TORCH, ammonia, amino acids in neonate
  • CPK, lactate, prolactin ?confirm seizure?

28
lumbar puncture
  • patients at greatest risk for meningitis
  • under 18 months of age
  • seizure in the ED
  • focal or prolonged seizure
  • seen a physician within the past 48 hours
  • other indications
  • concern about follow-up
  • prior treatment with antibiotics
  • The American Academy of Pediatrics
  • strongly consider in infants under 12 months of
    age with a first febrile seizure

29
neuroimaging
  • WHO? which patients?
  • WHAT? CT vs. MRI
  • ultrasound in neonates
  • WHEN? emergent vs. elective

30
ACEP guidelines - gt6 yo
  • consensus indication for non-contrast CT
  • first time seizure patients
  • if suspect structural lesion
  • partial onset seizure
  • age gt 40
  • no other identified cause
  • recurrent seizure patients
  • change in pattern
  • prolonged post-ictal period
  • worsening mental status

31
neuroimaging
  • predictors of abnormal findings of computed
    tomography of the head in pediatric patients
    presenting with seizures
  • Warden CR - Ann Emerg Med - 01-Apr-1997 29(4)
    518-23
  • retrospective case series
  • predicts CT scan results normal if
  • no underlying high-risk condition
  • malignancy, NCT, recent CHI, or recent CSF shunt
    revision
  • older than 6 months
  • sustained a seizure of 15 minutes or less
  • no new-onset focal neurologic deficit
  • not prospectively validated

32
emergent EEG?
  • not generally available on emergent basis
  • but consider in..
  • persistent altered mental status (?non convulsive
    status epilepticus)
  • paralyzed patients
  • pharmacologic coma

33
disposition
  • can be discharged home if
  • single seizure
  • stable, returning to baseline neuro status
  • no underlying condition/cause requiring treatment
    in hospital
  • arranged follow-up

34
EEG 1st non-febrile seizure
  • follow-up EEG
  • within 24h
  • Lancet 19983521007-11
  • improved pick-up 51 vs 34
  • ? how soon do we get ours ?
  • inter-ictal EEGs often normal
  • neuro may do sleep deprivation study
    (provocation)
  • absence epilepsy and infantile spasms are
    invariably associated with an abnormal EEG
  • spike and wave 3HZ

35
idiopathic seizure
  • recurrence risk stratification
  • normal EEG 25
  • abN EEG 60
  • 2nd seizure 75

36
neuroimaging
  • MRI superior
  • not emergently available
  • ?defer imaging until follow-up MRI available in
    low risk patients?

37
treatment
  • correct underlying pathology, if any
  • antipyretics ineffective in febrile seizure
  • anti-epileptic choice often trial and error
  • no anti-epileptic 100 effective
  • febrile seizure diazepam, phenobarbital,
    valproic acid
  • Currently AAP does not recommend
  • neonatal - phenobarbital
  • generalized TC phenytoin, phenobarbital,
    carbamazepine, valproic acid, primidone
  • absence ethosuximide, valproic acid
  • new anti-epileptics felbamate, gabapentin,
    lamotrigine, topiramate, tiagabine, vigabatrine
  • in consultation with neurologist

38
pediatric headache
39
case 5
  • 14 year old
  • mothers chief complaint - having headaches all
    the time, getting worse, this is not normal!!
    etc. etc……..
  • V/S N
  • looks in discomfort but otherwise well
  • approach?
  • treatment
  • imaging?

40
classification
  • classify based on temporal pattern
  • acute headaches
  • any febrile illness, sinus/dental infection,
    intracranial infection/bleed (AVM,SAH,trauma)
  • acute recurrent
  • chronic progressive
  • chronic non-progressive
  • tension, psychogenic, post-traumatic, ocular
    refractive error

41
acute recurrent headache
  • migraine
  • other
  • cluster headache typically gt10 yo
  • sinusitis
  • vascular malformation

42
migraine - terminology
  • classic migraine
  • biphasic
  • neuro aura
  • headache, N/V, anorexia, photophobia
  • either unilateral (older) / bilateral(younger) or
    both
  • common migraine
  • malaise, dizziness, N/V, feels and looks sick
  • unilateral/bilateral
  • migraine equivalent/complicated migraine
  • transient neuro deficits
  • /- headache
  • migraine variants
  • Cyclic N/V, abdo pain
  • BPV

43
migraine treatment
  • very little supporting evidence for pharmacologic
    treatment in children compared to adults
  • classes of medication
  • acetaminophen
  • NSAIDS
  • phenothiazines (dopamine antagonists)
  • dihydroergotamine
  • triptans

44
the simple stuff
  • acetaminophen 15 mg/kg PO 30mg/kg PR
  • ibuprofen 10 mg/kg PO
  • Hamalainen ML Ibuprofen or acetaminophen for the
    acute treatment of migraine in children A
    double-blind, randomized, placebo-controlled,
    crossover study
  • Neurology 48103-107, 1997
  • N 88 age 4-16
  • relief at 2 hours
  • acetaminophen 54
  • ibuprofen 68

45
other NSAIDS
  • naproxen 5-7 mg/kg PO
  • no pediatric evidence
  • ketorolac IV 0.5 mg/kg (max 30mg dose)
  • not studied in pediatric migraine
  • not approved lt16 yo
  • Houck CS Safety of intravenous ketorolac in
    children and cost savings with a unit dosing
    system. J Pediatr - 01-Aug-1996 129(2) 292-6
  • 1747 children
  • 0.2 hypersensitivity
  • 0.1 renal complications (in patients with renal
    disease)
  • 0.05 gi bleed

46
dihydroergotamine
  • not approved
  • ?dose 0.1 0.5 mg IV
  • not studied in emergency population
  • Linder SL Treatment of childhood migraine with
    dihydroergotamine mesylate Headache - 1994
    Nov-Dec 34(10) 578-80
  • N 30
  • inpatient protocol
  • IV DHE and PO metoclopramide average 5 doses!
  • 80 response

47
phenothiazines
  • again no studies
  • metoclopramide 1-2 mg/kg IV (max 10mg)
  • prochloperazine 0.1 0.15 mg/kg IV/IM/PO/PR (max
    10mg)
  • children may be more susceptible to EPS
  • ? pre-treat with benadryl

48
triptans
  • mostly studied in adolescent groups
  • sumitriptan subcutaneous 0.06mg/kg
  • Linder S Subcutaneous sumatriptan in the
    clinical setting The first 50 consecutive
    patients with acute migraine in a pediatric
    neurology office practice. Headache 36419422,
    1996
  • N 50 age 6-18
  • 78 effective at 2 hours
  • 6 recurrence
  • sumitriptan intranasal
  • long term treatment studies done
  • no emergent studies
  • triptans PO
  • studies plagued by high placebo response

49
chronic progressive headache
  • least common presentation
  • most worrisome for increased ICP
  • pseudotumor cerebri
  • space occupying lesion

50
imaging indications? discuss
  • lack of evidence to help
  • small studies lack power to guide decision making
  • MRI preferred in non-urgent indication

51
imaging indications? discuss
  • classically based on historical and physical
  • sudden severe headache
  • rapid increase over days - weeks
  • chronic progressive
  • suggestive of increased ICP
  • severe nocturnal headache (wakes or upon waking),
    changes in pain with position, coughing
  • following head trauma
  • persistent neuro findings
  • ? include migraine equivalents ?
  • growth abnormality
  • age (? lt3 ?)
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