Paediatric emergency department topic 1 Dr Julia Thomson General paediatric consultant with an interest in Emergency Paediatrics

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Paediatric emergency department topic 1Dr Julia
ThomsonGeneral paediatric consultant with an
interest in Emergency Paediatrics

• Emergency Management of the convulsing child
• Febrile convulsions

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Emergency management of the convulsing
childLearning objectives

• Assessment and support of the convulsing child
• Termination of a tonic-clonic convulsion

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Background

• Generalised convulsive (tonic-clonic) status
  epilepticus definition
• Generalised convulsion lasting 30 minutes or more
  or frequent successive convulsions over a period
  of 30 minutes or more with no regaining of
  consciousness in between.
• Outcome determined by underlying cause and by
  duration
• gt 5 minutes unlikely to terminate spontaneously
• Mortality in children from status epilepticus is
  about 4
• Airway obstruction, hypoxia, aspiration of vomit,
  overmedication, cardiac arrhythmias, underlying
  disease process

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Assessment of the convulsing child

• Assess and if necessary support
• A,B,C
• AIRWAY
• BREATHING
• CIRCULATION

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Assessment 2

• DISABILITY
• EXPOSURE
• F
• G
• Glucose!!

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Termination of seizure
Wait 10 minutes -gt
lt- Most children stop fitting by this point
If still in status 20 mins after phenytoin
started anaesthetist needs to draw up their drugs
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Questions on emergency management of a convulsing
child
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Summary

• Assessment and support of the convulsing child
• ABC DEFG
• 2222
• airway positioning /- suction
• O2
• glucose, fluid, antibiotics as required
• Termination of a tonic-clonic convulsion
• algorithm

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Worksheet
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Febrile convulsions

• Information from the Paediatric Epilepsy Training
  (PET 1) Manual, produced by BPNA

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Febrile convulsions learning objectives

• Understand the definition of and some background
  to febrile convulsions
• Be able to recognise whether a febrile seizure is
  simple or complex
• Have an idea of what to say to parents including
  the risk of recurrence and the risk of developing
  epilepsy

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definition

• an event occurring in infancy or childhood,
  usually between 3 months and 5 years of age,
  associated with a fever but without evidence of
  intracranial infection or defined cause for the
  seizure
• National Institute for Health, USA

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definition

• an event occurring in infancy or childhood,
  usually between 3 months and 5 years of age,
  associated with a fever but without evidence of
  intracranial infection or defined cause for the
  seizure
• National Institute for Health, USA
• Lower and upper age limits vary according to the
  source
• Presentation with 1st febrile seizure is rare
  after 5 years of age
• Peak incidence of first one is 9 to 20 months

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definition

• an event occurring in infancy or childhood,
  usually between 3 months and 5 years of age,
  associated with a fever but without evidence of
  intracranial infection or defined cause for the
  seizure
• National Institute for Health, USA
• No definition for fever
• Generally accepted as at least 38oC
• Fitting at lower temperatures is one of the
  factors to take into account when assessing the
  risk of recurrence

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definition

• an event occurring in infancy or childhood,
  usually between 3 months and 5 years of age,
  associated with a fever but without evidence of
  intracranial infection or defined cause for the
  seizure
• National Institute for Health, USA
• 1 of patients who have had a fit and have a high
  temperature have meningitis or encephalitis.
  These are therefore not febrile fits by
  definition.

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definition

• an event occurring in infancy or childhood,
  usually between 3 months and 5 years of age,
  associated with a fever but without evidence of
  intracranial infection or defined cause for the
  seizure
• National Institute for Health, USA
• Children with other neurological conditions, eg.
  CP, may fit when febrile. These also should not
  be diagnosed as febrile convulsions.

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Classification of febrile seizures
 SIMPLE COMPLEX 70 of febrile
fits accounts for 30 last under 10
minutes last more than 10 minutes generalised
focal features do not recur within 24 hours
nor do recur within the same during the same
illness illness
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Genetics

• Strong genetic basis for febrile seizures
• Risk to sibling of a child with febrile fits is
  25
• High concordance in monozygotic twins
• ?autosomal dominant, ?effect of multiple genes,
  ?mutations in specific genes
• Ask about the family history

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Parents questions 1

• Do lots of children get febrile seizures?
• They are common by 7 years, 3-4 of children
  will have had 1 or more febrile seizures
• Boys gt girls, black children gt white children

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Parents questions 2

• What is the chance that it will happen again?
• The overall recurrence risk is 30-40
• Predictors of risk are
• Age less than 18 months
• Family history of febrile seizures
• Low temperature at the time of the seizure
• Short duration of illness
• The number of the above risk factors present
  determines the likelihood of recurrence
• No risk factors 4 recurrence risk
• 1 risk factor 23
• 2 risk factors 32
• 3 risk factors 62
• 4 risk factors 76

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Parents questions 3

• How dangerous are they?
• Other than a potential risk of injury, short
  febrile seizures are not dangerous and will not
  cause brain damage
• Febrile seizures lasting over 30 minutes can be
  associated with appreciable morbidity and
  mortality

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Parents questions 4

• Has my child got epilepsy?
• In the vast majority of cases febrile seizures
  will not be followed by epilepsy
• The background population risk of epilepsy is
  0.5. The overall risk for children who have a
  febrile fit is a six-fold increase on this ie. 3
• Risk factors for developing epilepsy include
• Prior abnormal neurodevelopment
• Family history of afebrile seizures
• Complex febrile seizure
• Likelihood increases with the number of risk
  factors
• No risk factors same as population risk (0.5)
• 1 risk factor 6-8
• All 3 risk factors almost 50

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Questions on febrile convulsions
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Febrile convulsions summary

• Definition of febrile fit
• Discussed whether a febrile seizure is classified
  as simple or complex
• Have thought about what to say to parents
  including the risk of recurrence and the risk of
  developing epilepsy