Common Pediatric

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• Common Pediatric
• Neurological emergency
• Acute seizure attack / Status epilepticus
• Febrile convulsion

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Acute seizure attack / Status epilepticus
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Status Eilepticus
Definition More than 30 minutes of continuous
seizure activity or Two or more sequential
seizures spanning this period without full
recovery between seizures
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Status epilepticus

• 2 main types
• Convulsive SE Tonic clonic SE
• Non convulsive SE
• Practically considered every acute seizure attack
  to be risk for status epilepticus and if seizure
  is still going on after 5 mins, status
  epilepticus is considered
• 4 of neurological intensive care admission and
  about 0.1o of visits to emergency room

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Epidemiology

• common in
• - children less than 1 year old
  - adult more than 60
  year old

incidence 41/100,000 population 50
episodes/year/100,000 population Richmond
Virginia
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Pathogenesis

• The hippocampus was consistently activated
  during SE.
• Excitation of glutamatergic excitatory synaptic
  transmission in sustaining the SE.
• Loss of GABA-mediated inhibition in the
  hippocampus.

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HE subject
HE control
GFAP stain control
GFAP stain subject
CA1 Pyramidal cell layer
Dentate hilus (enfolium)
Entorhinal cortex
Periamydaloid cortex layer II
Reactive gliosis is present in regions with
neuronal loss
Denson G, et al. Epilepsia 200041981-991
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?????????????? SE ??????????????

• ???????
• Hypoxic-ischemic encephalopathy
• Infection
• Inborn errors of metabolism
• Stroke or intravascular hemorrhage
• Congenital malformation
• Pyridoxine deficiency and dependency

J Neuro Neurosurgy Psychiatry 199356125-134
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?????????????? SE ??????????????

• ???????
• Infection
• Febrile seizure
• Metabolic disturbance
• Congenital malformation
• Presentation of epilepsy

J Neuro Neurosurgy Psychiatry 199356125-134
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Precipitant of SE

• Precipitant Children (lt16 y)
  Adult (gt16 y)
• Cerebrovascular 3.3 25.2
• Antiepileptic change 19.8 18.9
• Anoxia 5.3 10.7
• Ethanol/drug-related 2.4 12.2
• Metabolic 8.2 8.8
• Unknown 9.3 8.1
• Infection/Fever 35.7 4.6
• Trauma 3.5 4.6
• Tumor 0.7 4.3
• CNS infection 4.8 1.8
• Congenital 7.0 0.8
• 
  Dorson WE et al. JAMA 1993270854-859

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Management of acute seizure

• 1. General supportive cares
• 2. Stops and controls seizure
• 3. Assessment for cause and Rx
• 4. Prevent complications

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General supportive Care in Mx of acute seizure/
Status epilepticus

• Position
• Suction secretion, clear airway
• O2 mask
• Rapid intubation if hypoventilated
• Dextrostix- 25 glucose 2 ml/kg IV
• Reduced fever
• Monitor P, BP, O2 saturation

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25 Glucose 2ml/Kg iv lt 18 mo B6 100mg iv
Acute seizure/SE
ABC
Acute seizure / Status epilepticus Management
Algorithm
IV/rectal diazepam 0.5 mg/kg
Seizures continue/ recur for 10-15 min
Hx PE. Initial lab
IV / rectal diazepam 0.5 mg/kg notgt2 doses
with long acting AED
IV phenytoin 20 mg/kg (rate 1 mg/kg/min)
seizure control
Maintenance AED
Seizures continue for 20 min
Maintenance AED
seizure control
IV phenytoin 10 mg/kg (rate 1 mg/kg/min)
Seizures continue for 20 min
Maintenance AED
IV phenobarbital 20 mg/kg
seizure control
Seizures continue for 20 min
seizure continue
IV phenobarbital 10 mg/kg
ICU EEG monitoring
Refractory SE
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Major drugs used to treat acute seizure in
children

• DZP
  PHT PB
• IV dose, range (mg/kg) 0.3-1.0 20
  20
• rectum dose (mg/kg) 0.5 -
  -
• max administration rate
  5mg/min 1mg/kg/min 1mg/kg/min
• time to stop seizure (min) 1-3 10-30
  20-30
• effective duration of action (hrs) 0.25-0.5
  24 gt48
• Potential side effects
• consciousness depression
  10-30 mins none several days
• respiratory depression
  occasional infrequent
  occasional
• hypotension
  infrequent occasional
  infrequent
• cardiac arrhythmia - in
  patient -
• with heart
• 
  disease
  

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Rapid sequence intubation

• Preoxygenation with oxygen mask positive
  pressure ventilation with cricoid pressure
• Atropine 0.01-0.02 mg/kg iv??????? gag reflex
  ?????? endotracheal tube
• Lidocaine 1.5-3.0 mg/kg iv ???????????????????????
  ??????????????????????????????
• Sedation ???? Thiopental 4-5 mg/kg iv
  ?????????????????????? hypotension ????
• Muscle relaxant ???? Pancuronium 0.6-1 mg/kg iv
• Intubation and test for proper position
• Oxygenation and suction clear airway

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• For nursing care
• Never force an airway or tongue blade in the
• seizing patients mouth
• Never restrained
• Always provided oxygen by cannular or face
• mask

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• You need to notify the doctor immediately and
  establish an
• airway if possible
• Intubation by anesthesiology may be necessary
• Oxygen is given
• IV access is established with 0.9 NaCl
• Be prepared to administer meds to stop motor
  movement
• Diazepam IV or rectally
• Phenobarbital
• Phenytoin
• Valproic acid
• Midazolam

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• FOR ALL TYPES OF SEIZURES YOU DOCUMENT
• Time seizure started and ended
• Loss of consciousness
• Type of clonic, tonic, atonic behaviors
• Loss of bowel or bladder control
• All treatment administered
• VS after patient is finished seizing
• Patients behavior after seizure
• If there was an aura
• Who was notified and orders received

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History Physical examination

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• ??????????? ??????? ????? ??????
• ?????????????????????????
• ?????????? ???????????
• Focal neurological signs
• Signs of systemic disease BP, T, Respiratory
  pattern,liver /renal disease, toxin/poisoning,
  neurocutaneous disorder

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• Lab investigations
• Initial (emergency) phase
• dextrostix ???????????????
• CBC, electrolyte, glucose, Ca,Mg,PO43-,
• BUN,creatinine ???????????????????????
• hemoculture ?????????????????????????????
• liver function test ?????????????????????????????
  ???????
• toxicology screening ???????????????????????????
• ?????????????????????? epilepsy
  ??????????????????????
• ammonia, metabolic screening for inborn errors

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• Lab investigations
• Second (follow stabilization) phase
• ????????????????????????????????
• Computed tomography of brain ????????????????????
  ???
• ?????????????????? (EEG)

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Status epilepticus

• Indications and contraincations for lumbar
  puncture
• Indications
• presence of meningeal sign
• febrile child lt18 month of age
• immunocompromised host
• Contraindications
• severe coagulopathy,throombocytopenia
• cardiopulmonary instability
• evidence of increased ICP
• focal seizure or focal neurological deficit
  (unless normal CT)
• infection at site of needle aspiration

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Status epilepticus

• Indication for emergency CT
• Head trauma
• Physical exams suggest increased ICP
• Focal neurological deficit
• Focal seizure activity

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Systemic complications of status epilepticus
Early lt30 min
Late gt30 min
Parameter
Complication

• BP Increase Decrease Hypotonia
• PaO2 Decrease Decrease/ Hypoxia
• variable
• PaCO2 Increase Decrease Increase ICP
• Serum pH Increase 300 Increase
  Acidosis
• Temperature Increase 1. C Increase 2. C
  Fever
• Autonomic Increase Increase Arrythmia
• activity

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Systemic complications of status epilepticus
Early lt30 min
Late gt30 min
Parameter
Complication

• Lung fluids Increase Increase
  Atelectasis
• Serum K Increase Increase Arrhythmia
• Serum CPK Normal Increase Renal
  failure
• CBF Increase 900 Increase 200 Cerebral
  bleed
• Cerebral O2 Increase 300 Increase 200
  Ischemia
• consumption

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Medical complications of SE
Cerebral

• Hypoxia/metabolic damage
• Seizure-induced cerebral damage
• Cerebral edema and raised intracranial pressure
• Cerebral venous thrombosis
• Cerebral hemorrhage and infarction

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Medical complications of SE
Cardiovascular

• Hypotension
• Hypertension
• Cardiac failure
• Tachyarrhythmias and bradyarrhythmias, cardiac
  arrest

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Medical complications of SE
Respiratory and Autonomic

• Respiratory failure
• Pulmonary edema, hypertension and embolism
• Pneumonia and aspiration
• Hyperpyrexia
• Sweating, hypersecretion, tracheobronchial
  obstruction

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Medical complications of SE
Metabolic

• Dehydration
• Electrolyte disturbances (hyponatremia,
  hyperkalemia)
• Hypoglycemia
• Acute renal failure
• Acute hepatic failure
• Acute pancreatitis

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Medical complications of SE
Others

• Disseminated intravascular coagulation
• Rhabdomyolysis
• Fractures
• Infection (lung, skin, bladder)
• Deep venous thromboses

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Refractory SE

• SE that fails to benzodiazepine, phenytoin and
  phenobarbital
• 9 of GCSE failed the sequential administration
  of BZP, PHT, PB

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Treatment of refractory SE

• Valproate 15-20mg/kg iv follow by 1mg/kg/hr
• Midazolam 0.3-0.5 mg/kg IV follow by
  0.1-0.3mg/kg/hr for 3-5 days
• Diazepam continuously IV start dose of 0.03
  mg/kg/min increased by 0.005 mg/kg/min every
  15 min
• Thiopental start dose 5-15 mg/kg IV followed by
  5 mg/kg/hr
• Pentobarbital 5-15mg/kg iv followed by
  1-10mg/kg/hr
• Propofal start dose 1-2 mg/kg followed by
  2-10 mg/kg/hr

Control until burst suppression activity for
24-48 hours then tape off in 12-24 hrs if recurs
repeat medications
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Prognosis

• Intermittent SE has good prognosis than
  continuous SE
• mortality in children 2.5-15
• mortality in adult 15-25
• SE more than 2 hrs always has permanent
  neurological deficit

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Prognosis

• Treatment factors
• The time elapsed before control of SE
• SE of long duration is less responsive to drug Rx
  than of shorter duration
• The adverse effect of agent commonly used when SE
  is refractory to the usual drugs

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Prognosis

• Cognitive or motor deficit are related to the
  underlying cause rather than the actual seizure
• Movement disorders were observed in SE gt30 min

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Prevention

• Advise for regular AED
• Avoid precipitating factors
• Advise for acute seizures control at home

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Normal neuronal firing
Glia
Action potential
K
mV
0
Na in
K out
- 40
Recorded intramembrane potential
Threshold
E
- 70
Resting potential
I
I
E
E
IPSP
AHP
EPSP
Na
Na
outside
Lipid layer
Axon
Na K ATP ase
K
inside
K
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Excitatory
Postsynaptic
Presynaptic
Voltage- gate ion channel
Non NMDA
Glutamate
Glutamate receptor complexes
NMDA
Na
K
Ca
NMDA receptor-ion pore complex
Mg
Glutamate binding site
Glycerine co-activator site
Ion pore
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Abnormal neuronal firing
A) Brain
EEG
Normal
Interictal
ictal
intracellular
B) Neuronal network
PDS
E
NMDA
Non NMDA
PDS
Non NMDA
E
I
delay
I PSP
EPSP
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Inhibitory
Presynaptic terminal
Postsynaptic terminal
GABA receptor
GAD
Glutamate
GABA
B6
Cl-
Ca