The ACEP Seizure Clinical Policy: What About Pediatric Patients

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The ACEP Seizure Clinical Policy What About
Pediatric Patients
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Andy S. Jagoda, MD
Professor and Vice ChairResidency Program
DirectorDepartment of Emergency MedicineMount
Sinai School of MedicineNew York, NY
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Learning Objectives

• Discuss the development of clinical policies and
  their relevance to ED clinical practice
• Describe the recommended treatment strategies of
  pediatric ED seizures and status epilepticus
• Present seizure patient scenarios that will allow
  help clinical decision making in caring for the
  pediatric seizure patient

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Ann Emerg Med 200443605

• Clinical policy Critical issues in the
  evaluation and management of adult patients
  presenting to the emergency department with
  seizures
• Not a comprehensive manual
• No substitute for clinicians judgment

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Why are Clinical Policies being Written?

• Differentiate evidence based practice from
  opinion based
• Clinical decision making
• Education
• Reducing the risk of legal liability for
  negligence
• Improve quality of health care
• Assist in diagnostic and therapeutic management
• Improve resource utilization
• May decrease or increase costs
• Identify areas in need of research

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Interpreting the Literature

• Terminology
• Status epilepticus
• Patient population
• Children vs adults
• Interventions / outcomes
• Termination of motor activity vs termination of
  electrical activity

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Description of the Process

• Medical literature search
• Secondary search of references
• Articles graded
• Recommendations based on strength of evidence
• Multi-specialty and peer review

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Description of the Process

• Strength of evidence (Class of evidence)
• I Randomized, double blind interventional
  studies for therapeutic effectiveness
  prospective cohort for diagnostic testing or
  prognosis
• II Retrospective cohorts, case control studies,
  cross-sectional studies
• III Observational reports consensus reports
• Strength of evidence can be downgraded based on
  methodologic flaws

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Case Studies Lab Testing

• Case 1 12 yo healthy boy has a witnessed tonic
  clonic seizure that lasts 30 seconds followed by
  a half hour post ictal period he is alert with a
  normal neurologic exam in the ED.
• Case 2 A 2 yo healthy infant rapidly develops a
  fever of 39 and has a witnessed tonic clonic
  seizure lasting 2 minutes. In the ED he is alert
  with a normal exam.

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Lab Testing

• What laboratory tests are indicated in the
  otherwise healthy pediatric patient with a
  new-onset seizure who has returned to a baseline
  normal neurological status?
• What about pediatric patients with febrile
  seizures?

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ACEP Clinical Policy Lab Testing

• Level A recommendations None
• Level B recommendations
• Determine a serum glucose and sodium level on
  patients with first-time seizure with no
  comorbidities who have returned to their
  baseline.
• Obtain a pregnancy test if a woman is of
  child-bearing age.

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ACEP Clinical Policy Lab Testing

• The policy suggests that a serum glucose and
  sodium determinations are appropriate in Case 1.
  
• The policy discusses the role of toxicologic
  screens but due to lack of evidence is unable to
  make any specific recommendations

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Lab Testing Case 1

• The patient and friends are suspected of
  experimenting with cocaine
• Toxicologic analysis confirmed the presence of
  cocaine metabolites
• The patient in Case 1 is diagnosed with a drug
  related seizure
• Does he need a neuroimaging study?
• Does he need an EEG?
• Should he be treated with an AED?

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Lab Test Case 2

• The patient meets the criteria for a simple
  febrile seizure
• 6 mo 5 years
• Nonfocal, generalized seizure
• Related to rapid onset fever
• Last
• Adults do not get simple febrile seizures

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Evaluating a first nonfebrile seizure in
children. Neurology 2000 55616-623

• Laboratory tests
• Laboratory tests should be ordered based on
  individual clinical circumstances that include
  suggestive historic or chinical findings such as
  vomiting, diarrhea, dehydration, or failure to
  return to baseline alertness (option)
• Glucose and sodium low yeild but high value
• Toxicology screening should be considered across
  the entire pediatric age range if there is any
  question of drug exposure or substance abuse
  (option)

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The neurodiagnostic evaluation of the child with
a first simple febrile seizure. Pediatrics 1996
97769-775.

• Blood studies
• Blood studies (electrolytes, calcium, phosphate,
  magnesium, CBC, blood glucose) are not
  recommended routinely in the evaluation of a
  child with a first simple febrile seizure

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The neurodiagnostic evaluation of a first simple
febrile seizure. Pediatrics 1996 97769-775.

• Lumbar puncture
• Strongly considered in infants younger than 12
  months and infants and children who have received
  prior antibiotics
• Considered in children 12 18 months although a
  LP is not routinely warrented
• Not routinely warrented in children 18 months

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Case Studies Neuroimaging

• Case 1 12 yo healthy boy has a witnessed tonic
  clonic seizure that lasts 30 seconds followed by
  a half hour post ictal period he is alert with a
  normal neurologic exam in the ED.
• Case 2 A 2 yo healthy infant with a URI
  develops a fever of 39 and has a witnessed tonic
  clonic seizure lasting 60 seconds. In the ED he
  is alert with a normal exam.

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Neuroimaging

• Which new-onset pediatric seizure patients who
  have returned to a normal baseline require a head
  CT in the ED?
• Focal neurologic findings and / or history of
  trauma or CNS disorder increase incidence of
  pathologic findings

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ACEP Clinical Policy Neuroimaging

• Level A recommendations - None
• Level B recommendations
• When feasible, perform neuroimaging of the brain
  in the ED on patients with a first-time seizure.
• Deferred outpatient neuroimaging may be used when
  reliable follow-up is available.

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ACEP Clinical Policy Neuroimaging

• The ACEP Clinical Policy suggests that imaging
  may be deferred in Case 1
• CTs rarely change immediate management in the
  patient with a normal neuro exam but have
  significant impact on disposition and on
  initiation of AED treatment
• Risk of ioning radiation in children is an
  important concern

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Evaluating a first nonfebrile seizure in
children. Neurology 2000 55616-623

• Neuroimaging
• If a neuroimaging study is obtained, MRI is the
  preferred modality (guideline)
• Emergent neuroimaging should be performed in a
  child of any age who exhibits a postictal focal
  deficit not quickly resolving, or who has not
  returned to baseline within several hours after
  the seizure (option)

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ACEP Clinical Policy EEG

• When should EEG testing be performed in the ED?
• Level C Consider an emergent EEG in patients
  suspected of being in nonconvulsive status
  epilepticus or in subtle convulsive status
  epilepticus, patients who have received a
  long-acting paralytic, or patients who are in
  drug-induced coma.

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Evaluating a first nonfebrile seizure in
children. Neurology 2000 55616-623

• EEG
• The EEG is recommended as part of the
  neurodiagnostic evaluation of the child with an
  apparent first unprovoked seizure (standard)
• Timing of EEG is not specified

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ACEP Clinical Policy Disposition and Treatment

• Case 1 12 yo healthy boy has a tonic clonic sz
  that lasts 30 seconds followed by a half hour
  post ictal period he is alert with a normal
  neurologic exam in the ED.
• Lab tests are normal. EEG / MRI pending
• Would you admit this patient?
• Would you start this patient on an AED?

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ACEP Clinical Policy Disposition and Treatment

• Level A / B recommendations - None
• Level C recommendations
• Patients with a normal neurologic examination can
  be discharged from the ED with outpatient
  follow-up.
• Patients with a normal neurologic examination, no
  comorbidities, and no known structural brain
  disease do not need to be started on an
  antiepileptic drug in the ED.

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Treatment of the child with a first unprovoked
seizure. Neurology 2003 60166-175

• Historically children were started on an AED
  after a first unprovoked seizure
• Attempt to prevent kindling thus development of
  epilepsy
• Prevent risk of injury

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Treatment of the child with a first unprovoked
seizure. Neurology 2003 60166-175

• Seizure recurrence after first unprovoked seizure
  20 - 50
• Abnormal EEG and / or neuroimaging increases risk
  of seizure recurrence
• Availability of testing and follow-up determines
  need for admission

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Treatment of the child with a first unprovoked
seizure. Neurology 2003 60166-175

• Treatment with AED is not indicated for the
  prevention of the development of epilepsy (level
  B)
• Treatment with AED may be considered in
  circumstances where the benefits of reducing the
  risk of a second seizure outweigh the risks of
  pharmacologic and psychosocial side effects
  (level B)

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ACEP Clinical Policy Phenytoin Dosing Strategies

• What are effective phenytoin or fosphenytoin
  dosing strategies for preventing seizure
  recurrence in patient who present to the ED after
  having had a seizure with a subtherapeutic serum
  phenytoin level?
• Limited applicability to pediatric population
  since other AEDs have less side effects and
  better tolerability

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ACEP Clinical Policy Phenytoin Dosing Strategies

• Level C recommendation Administer an intravenous
  or oral loading dose of phenytoin or intravenous
  or intramuscular fosphenytoin, and restart daily
  oral maintenance dosing.

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ACEP Clinical Policy Status Epilepticus

• The 12 yo boy in Case 1 had a positive EEG and a
  MRI that demonstrated hippocampal scarring. A
  diagnosis of partial epilepsy with secondary
  generalization was made and he was started on
  valproic acid.
• 6 months later he returns to the ED via EMS
  having had 3 generalized events without return to
  baseline

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ACEP Clinical Policy Status Epilepticus

• Upon arrival in the ED he has a fourth tonic
  clonic event that does not stop.
• After the ABCs and blood sugar are addressed
• What is your first line AED?
• What is your second line AED?
• How do you manage refractory status epilepticus?

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ACEP Clinical Policy Status Epilepticus

• What agent(s) should be administered to a patient
  in status epilepticus who continues to seize
  after having received a benzodiazepine and a
  phenytoin?
• Are there patients where phenytoin should not be
  used as a second line agent?

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ACEP Clinical Policy Status Epilepticus

• Level C Administer 1 of the following agents
  intravenously
• high-dose phenytoin
• Phenobarbital
• valproic acid
• midazolam infusion
• pentobarbital infusion
• propofol infusion.

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ACEP Clinical Policy Status Epilepticus

• Though there are many opinions, no data exist to
  guide specific therapies.
• It would seem reasonable to empirically
  administer valproate, particularly if levels are
  demonstrated to be low.
• The new antiepileptic drugs pose a challenge
  since levels cannot be determined.

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Summary

• Evidence based clinical policies are useful tools
  in clinical decision making
• Clinical policies do not create a standard of
  care but do provide a foundation for clinical
  practice at a national level
• The current literature on acute seizure
  management in children, as in adults, does not
  support the creation of level A
  recommendations and there is need for future
  research to help clarify many of our diagnostic
  and treatment strategies

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Questions??

• www.ferne.orgferne_at_ferne.orgAndy S. Jagoda,
  MDandy.jagoda_at_mountsinai.org

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8/29/2005 535 AM