Challenging Pediatric Seizure and SE Cases

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Challenging Pediatric Seizure and SE Cases
Edward P. Sloan, MD, MPH, FACEP
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Edward P. Sloan, MD, MPH

• Professor
• Dept of Emergency Medicine University of Illinois
  College of Medicine
• Chicago, IL

Edward P. Sloan, MD, MPH, FACEP
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Attending Physician Emergency Medicine

• University of Illinois Hospital
• Our Lady of the Resurrection Hospital
• Chicago, IL

Edward P. Sloan, MD, MPH, FACEP
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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

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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)

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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

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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

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Case 1 Seizing infant, no IV access

• What therapies can be given?
• By what route?
• With what effect?

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Case 1Hx

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

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Case 1Px

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

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Case 1Dx

• What are the diagnoses in this child?

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Case 1Dx

• Generalized convulsive status epilepticus (GCSE)
• Complex febrile seizure

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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

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Case 1Rx Non-IV Options

• IM midazolam
• Buccal midazolam
• IM fosphenytoin
• PR diazepam
• PR diazepam rectal gel
• IM phenobarbital less good

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Case 2 Pediatric SE

• How do we diagnose ped SE?
• What is the optimal Rx protocol?
• Why?

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Case 2Hx

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

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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

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Case 2Px

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

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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

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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

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Case 2Dx

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

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Case 2Rx

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

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Case 2Rx

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

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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

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Case 2Rx

• IV lorazepam
• IV valproate
• Transfer to Childrens for ICU observation

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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?

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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

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Case 3Px

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

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Case 3Dx

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

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Case 3Rx

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

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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

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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

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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?

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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

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Case 4Px

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

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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

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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

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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

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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?

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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

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Case 5Px

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

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Case 5Question 1

• What diagnostic tests are indicated at this point?

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Case 5Question 2

• Did this patient have a seizure?
• Yes
• No

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Case 5Question 3

• Does the patient require admission for
  observation for possible new onset seizures?
• Yes
• No

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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

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Case 5Question 4

• Is this repeat spell a seizure?
• What type?

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Case 5Question 5

• Does this AMS, motor activity require Rx?
• What Rx?

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Case 5Question 6

• Does the patient require admission for
  observation for possible new onset seizures?

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Case 5Clinical Course (cont)

• During EEG, pt with R face focal sz
• Leftward gaze noted
• Seizure then generalizes
• Meds are given
• Seizure is terminated

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Case 5Question 7

• What med is to be used for seizure control / SE
  termination?

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Case 5Question 8

• What med is to be used once SE is terminated?
• Why?

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Case 5Question 9

• How should the meds be given?
• Why?

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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

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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

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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

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Case 5Dx

• New onset seizure/SE
• Complex partial seizure with generalized seizures
• Hx migraine headaches

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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

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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

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CME Question

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

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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

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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