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Challenging Pediatric Seizure and SE Cases

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Title: Challenging Pediatric Seizure and SE Cases


1
Challenging Pediatric Seizure and SE Cases
Edward P. Sloan, MD, MPH, FACEP
1
2
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
3
Attending Physician Emergency Medicine
  • University of Illinois Hospital
  • Our Lady of the Resurrection Hospital
  • Chicago, IL

Edward P. Sloan, MD, MPH, FACEP
3
4
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

5
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)

6
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

7
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

8
Case 1 Seizing infant, no IV access
  • What therapies can be given?
  • By what route?
  • With what effect?

9
Case 1Hx
  • 9 month old
  • Febrile illness at home
  • Seizing for paramedics
  • Arrives in arms of CFD
  • No IV access in field

10
Case 1Px
  • Hyperpyrexia, abn vital signs
  • Actively seizing, generalized
  • Tonic-clonic motor activity
  • Cardiopulm exam OK
  • No IV access available

11
Case 1Dx
  • What are the diagnoses in this child?

12
Case 1Dx
  • Generalized convulsive status epilepticus (GCSE)
  • Complex febrile seizure

13
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

14
Case 1Rx Non-IV Options
  • IM midazolam
  • Buccal midazolam
  • IM fosphenytoin
  • PR diazepam
  • PR diazepam rectal gel
  • IM phenobarbital less good

15
Case 2 Pediatric SE
  • How do we diagnose ped SE?
  • What is the optimal Rx protocol?
  • Why?

16
Case 2Hx
  • 7 year old male
  • Seizure-like activity?
  • Patient with staring spells
  • Some headache and shaking movement, esp of hands
  • Frontal headache, vomiting

17
Case 2Hx (cont)
  • 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

18
Case 2Px
  • 98.7 98/60 72 20
  • Well hydrated
  • CV, lung exams normal
  • Neuro exam intact

19
Case 2Px (cont)
  • 0220 episode
  • Tachycardia, assoc with AMS
  • Confused, staring off into space
  • Resolved without any Rx
  • Three more episodes over 40
  • Diaphoresis, urinary incontinence

20
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

21
Case 2Dx
  • Repetitive episodes with AMS
  • Rule out generalized nonconvulsive status
    epilepticus
  • Rule out complex partial status epilepticus
  • Associated autonomic signs

22
Case 2Rx
  • How would you initially treat this pediatric
    seizure patient?
  • IV diazepam
  • IV lorazepam
  • IV phenobarbital
  • IV valproate
  • Other

23
Case 2Rx
  • Would you load this patient with another
    antiepileptic drug prior to transfer to the
    childrens hospital?
  • Yes
  • No

24
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

25
Case 2Rx
  • IV lorazepam
  • IV valproate
  • Transfer to Childrens for ICU observation

26
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?

27
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

28
Case 3Px
  • VS OK prior to seizure
  • Chest Clear
  • CV Reg without
  • Neuro Non-focal
  • Generalized tonic-clonic seizure

29
Case 3Dx
  • Generalized seizures
  • Hx complex partial seizures
  • Sub-therapeutic valproate level vs. break-thru
    seizure

30
Case 3Rx
  • After an initial dose of a benzodiazepine is
    given, would you obtain a valproate level prior
    to giving IV valproate?
  • Yes
  • No

31
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

32
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

33
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?

34
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

35
Case 4Px
  • Vitals OK
  • Neuro slightly post-ictal
  • Exam otherwise normal
  • Patient has a 2nd seizure in the ED

36
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

37
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

38
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

39
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?

40
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

41
Case 5Px
  • Vitals OK, afebrile
  • Alert, O x 3, NAD
  • Head/Neck OK
  • Chest/cor/abd OK
  • Neuro No focal deficit. MS OK

42
Case 5Question 1
  • What diagnostic tests are indicated at this point?

43
Case 5Question 2
  • Did this patient have a seizure?
  • Yes
  • No

44
Case 5Question 3
  • Does the patient require admission for
    observation for possible new onset seizures?
  • Yes
  • No

45
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

46
Case 5Question 4
  • Is this repeat spell a seizure?
  • What type?

47
Case 5Question 5
  • Does this AMS, motor activity require Rx?
  • What Rx?

48
Case 5Question 6
  • Does the patient require admission for
    observation for possible new onset seizures?

49
Case 5Clinical Course (cont)
  • During EEG, pt with R face focal sz
  • Leftward gaze noted
  • Seizure then generalizes
  • Meds are given
  • Seizure is terminated

50
Case 5Question 7
  • What med is to be used for seizure control / SE
    termination?

51
Case 5Question 8
  • What med is to be used once SE is terminated?
  • Why?

52
Case 5Question 9
  • How should the meds be given?
  • Why?

53
Case 5Clinical Course (cont)
  • SE terminated with Rx
  • Pt stabilized
  • ALS transfer to Childrens with team
  • Pt with resolving AMS at time of D/C

54
Case 5Rx
  • Lorazepam to Rx the acute sz
  • Valproate for ongoing protection
  • Loaded over 20 minutes
  • IV phenytoin, fosphenytoin are options
  • PRN meds during transfer

55
Case 5Dx
  • What is the diagnosis in this young patient?
  • Absence seizure
  • Complex partial seizures with secondary
    generalized seizure
  • Focal motor seizure
  • Complex migraine headache

56
Case 5Dx
  • New onset seizure/SE
  • Complex partial seizure with generalized seizures
  • Hx migraine headaches

57
Case 5Dx
  • Do you believe you could diagnose a seizure on an
    EEG?
  • Yes
  • No

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ConclusionsKey Learning Points
  • Acute, repetitive spells sz
  • Multiple meds and routes possible
  • Opportunity to optimize Rx
  • Acute seizure control IV benzos
  • 2nd line Rx may differ based on Dx
  • Ongoing needs may influence 2nd Rx
  • EEG may be of use in ED seizures

66
RecommendationsManagement Implications
  • Educate about sz etiologies
  • Make multiple drugs available
  • Alternate routes should be used
  • A protocol should exist
  • Utilize EEG when necessary
  • Be aware of optimal Rx at disposition

67
CME Question
  • Have you learned something new about pediatric
    seizures today such that you can change and
    improve your clinical practice?
  • Yes
  • No

68
CME Follow-up
  • CME providers require follow-up to assess if your
    learning has indeed improved your clinical
    practice. Can we ask you this question via email
    again in 3 months?
  • Yes
  • No

69
Questions??
www.ferne.orgferne_at_ferne.orgEdward P. Sloan,
MD, MPH, FACEPedsloan_at_uic.edu312-413-7490
ferne_2005_acep_peds_sloan_szse_pedsrx_fshow.ppt
4/10/2005 1030 AM
Edward P. Sloan, MD, MPH, FACEP
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