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Pediatric Neurologic Emergencies

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... trauma, poisoning, drug/med use aura Seizure what movements incl. eyes how long LOC? consequences ... Paralyzed patients Barbiturate coma Disposition EEG ... – 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
  • Migraine treatment
  • Imaging indications

3
seizure
  • Febrile seizure
  • New onset nonfebrile seizure
  • Established seizure disorder with recurrence
  • Status epilepticus
  • Neonatal seizure

4
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

5
definitions
  • Status epilepticus
  • Neonatal seizure in first 28 days of life
    (typically first few days)
  • lt4 days hypoxic-ischemic encephalopathy, vit
    deficiency, drug withdrawal, lytes abN
  • gt4 days CNS infections

6
classification
  • Generalized
  • LOC
  • tonic, clonic, tonic-clonic, myoclonic, atonic,
    absence
  • Partial focal onset
  • Simple partial no LOC
  • Complex partial LOC
  • Partial secondarily generalized
  • unclassified

7
etiology
  • Infectious
  • Metabolic
  • Traumatic
  • Toxic
  • Neoplastic
  • Epileptic
  • other

8
Differential diagnosis
  • Syncope
  • Breath holding
  • Sleep disorders (eg. narcolepsy)
  • Paroxysmal movement disorders tics, tremors
  • Migraines
  • Psychogenic seizures

9
Approach to febrile seizuresthe 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

10
Simple febrile seizure
  • lt 15 mins
  • No focal features
  • No greater than 1 episode in 24h
  • neurologically and developmentally normal

11
Complex febrile seizure
  • gt15 min
  • Febrile epilepticus gt30min or recurrent without
    regaining consciousness gt 30min
  • Focal
  • Recurrence within 24h

12
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

13
Neonatal seizure
  • Brief and subtle
  • Eye blinking
  • Mouth/tongue movements
  • bicycling
  • Autonomic changes
  • EEG less predictable

14
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

15
status epilepticus
  • Definition
  • Seizure 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

16
SE treatment considerations
  • ABCs
  • glucose
  • Antibiotics/antivirals
  • if meningitis/encephalitis considered

17
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

18
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

19
Refractory SE treatment
  • Consider midazolam
  • 0.2 mg/kg bolus
  • 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

20
Approach stable post seizure
  • History
  • Pre-seizure
  • what was child doing when attack occurred
  • precipitants fever, trauma, poisoning, drug/med
    use
  • aura
  • Seizure
  • what movements incl. eyes
  • how long
  • LOC?
  • consequences resp distress, incontinence,
    injury
  • Post seizure
  • Post-ictal

21
Approach to stable patient
  • Physical directed towards
  • systemic disease
  • infection
  • toxic exposure
  • focal neuro signs

22
laboratory
  • Blood glucose?
  • Electrolytes?
  • Magnesium, calcium?
  • Anything at all?
  • What about first time seizures? Recurrent?
  • Yes if
  • neonatal
  • Abnormal mental status persistent
  • Diabetics, renal disease
  • Diuretic use
  • Dehydration
  • malnourishment

23
laboratory
  • septic work-up as indicated
  • CBC, BC, urine CS, CXR, LP
  • therapeutic drug levels
  • other
  • ABG
  • Toxicologic screen
  • TORCH, ammonia, amino acids in neonate
  • CPK, lactate, prolactin ?confirm seizure?

24
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.

25
neuroimaging
  • WHO? which patients?
  • WHAT? CT vs. MRI
  • ultrasound in neonates
  • WHEN? emergent vs. elective

26
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

27
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

28
neuroimaging
  • MRI superior
  • not emergently available
  • ?defer imaging until follow-up MRI available in
    low risk patients?

29
Emergent EEG?
  • Not generally available on emergent basis
  • But consider in..
  • Persistent altered mental status (?non convulsive
    status epilepticus)
  • Paralyzed patients
  • Barbiturate coma

30
Disposition
31
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

32
Idiopathic seizureRecurrence risk stratification
  • Normal EEG 25
  • abN EEG 60
  • 2nd seizure 75

33
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

34
pediatric headache
35
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

36
acute recurrent headache
  • migraine
  • other
  • cluster headache typically gt10 yo
  • sinusitis
  • vascular malformation

37
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

38
migraine treatment
  • very little supporting evidence for pharmacologic
    treatment in children compared to adults
  • classes of medication
  • acetaminophen
  • NSAIDS
  • Phenothiazines (dopamine antagonists)
  • Dihydroergotamine
  • Triptans not emergent treatment

39
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

40
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

41
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

42
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

43
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
  • Intranasal sumitriptan
  • Long term treatment studies done
  • No emergent studies
  • PO triptans
  • Studies plagued by high placebo response

44
Chronic progressive headache
  • least common
  • most worrisome
  • Increased ICP
  • Pseudotumor cerebri
  • Brain space occupying lesion

45
imaging indications? discuss
  • lack of evidence to help
  • small studies lack power to guide decision making
  • MRI preferred in non-urgent indication

46
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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