Evaluation and Management of Pediatric Seizures NIKKI MEHTA
- Slides: 20
Evaluation and Management of Pediatric Seizures NIKKI MEHTA, MD PEDIATRIC NEUROLOGY FLOATING HOSPITAL FOR CHILDREN AT TUFTS MEDICAL CENTER MAY 9, 2019 PEDIATRIC EMERGENCY MEDICINE, ECHO LECTURE
Objectives �To define seizures and epilepsy �To categorize type of seizure and identify characteristics that warrant additional evaluations �To differentiate simple from complex febrile seizure �To review treatment strategies for status epilepticus
Disclosures �None
What is a seizure? �Seizures are defined as abnormal, excessive synchronous neuronal activity in the brain �A. normal EEG �B. seizure
What is Epilepsy? �Epilepsy is diagnosed when a person has had 2 or more unprovoked seizures occuring greater than 24 hours apart �OR one unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two seizures (60%) occuring over the next 10 years Untreatable Tumors Scarring from a prior infarction The presence of an epileptogenic brain malformation �The diagnosis of an Epilepsy Syndrome
Classification of Seizures �Generalized Tonic Clonic Seizure Absence Myoclonic Atonic �Focal Simple motor Complex partial Sensory or Autonomic
Partial Seizures
Sensory and Autonomic Seizures
Febrile Seizures �Common in children- up to 4% of all children <5 years of age can have them �Occur in the presence of fever, but without signs of CNS infection or other identifiable cause �Inclusion Criteria Must fall within typical age range (6 months to 6 years) Must be developmentally normal for age Must not have had prior afebrile seizures Must have fever >38 F in association with the seizure
Simple vs Complex Febrile Seizure �Why differentiate? �Patients with Simple Febrile seizures have a near population risk of development of epilepsy �Patients with Complex Febrile Seizures have 5 -10% risk of developing epilepsy
Simple vs Complex Febrile Seizure
Febrile Status Epilepticus �Febrile Seizures lasting longer than 30 minutes or recurrent episodes of same duration without neurologic recovery in between �Treat as Status Epilepticus �Consider (strongly) evaluation for CNS Infection
Status Epilepticus �The majority of pediatric seizures are self limited to <5 minutes �After 5 minutes, likelihood a seizure will stop on its own precipitously drops �Internalization of neuronal GABA receptors, up to 20 fold by 30 minutes �Convulsive Status Epilepticus is defined as seizure lasting >5 minutes, or recurring without return to neurologic baseline in between
Treatment of Seizures � Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Jan 2016 � Based on large meta analysis of many RCTs treating both adults and children � Guideline is valid for all people >1 month old (same for adults and kids)
Stabilization Phase (0 -5 min) �Airway, Breathing, Circulation, Neuro Exam �Time the seizure onset �O 2 support �Establish IV access �Fingerstick Glucose and Electrolyte panel, Tox if appropriate
First Line Therapy Phase (5 -20 min) �If seizure continues, administer first line medication �IV Lorazepam (0. 1 mg/kg, max 4 mg) , IV Diazepam, or IM Midazolam �Treating adequately at first is more likely to stop seizure that repeated small doses �Respiratory depression is most common side effect, expect it and prepare airway support if needed �Can repeat x 1 if seizure continues after 5 minutes
Second Line Therapy (20 -40 min) �No clear winner for what to use next IV Phenytoin/Fosphenytoin (20 mg/kg x 1) IV Valproic Acid (40 mg/kg x 1) IV Levetiracetam (60 mg/kg x 1) �Consider transfer to center with Pediatric Neurology
DOI: (10. 5698/1535 -7597 -16. 1. 48)
Workup: Now, Later, Never? �Now- Consider Labs, Neuroimaging, and/or EEG Patients with clinical history of partial/focal seizure Patients with persistent focal neurologic deficits- Seizure is a first presentation for ~50% of all Pediatric Strokes! Patients who are not rousing/have prolonged encephalopathy beyond expected postictal period (concern for tox, NAT, encephalitis) Patients with status epilepticus (particularly the first episode) �Later- Can be referred to outpatient Pediatric Neurology for consult and workup (1 -4 weeks, depending on severity) Patients with first afebrile seizure (of any kind), if back to baseline in ED Patients with complex febrile seizure (clusters, prolonged), now back to baseline
Workup: Now, Later, Never? �Never Simple Febrile Seizure, meeting all inclusion criteria +/- Complex Febrile Seizure if the reason it is complex is >2 in 24 hours
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