Case Based Peds in your ED My kid is seizing My kid is vomiting My kid is having trouble...
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Transcript of Case Based Peds in your ED My kid is seizing My kid is vomiting My kid is having trouble...
Case Based Peds in your EDCase Based Peds in your ED
My kid is seizingMy kid is seizing My kid is vomitingMy kid is vomiting My kid is having trouble breathingMy kid is having trouble breathing My baby stopped breathingMy baby stopped breathing
20 cases over the next 90 minutes20 cases over the next 90 minutes Audience participation is Audience participation is requestedrequested
Case Based Peds in your EDCase Based Peds in your ED
My kid is seizingMy kid is seizing My kid is vomitingMy kid is vomiting My kid is having trouble breathingMy kid is having trouble breathing My baby stopped breathingMy baby stopped breathing
20 cases over the next 90 minutes20 cases over the next 90 minutes Audience participation is Audience participation is requiredrequired
Managing Seizures in Managing Seizures in Pediatric PatientsPediatric Patients
in your EDin your ED
Frank Overly, MDFrank Overly, MDAssistant Professor Emergency Medicine and Assistant Professor Emergency Medicine and
PediatricsPediatrics
Alpert Medical School of Brown UniversityAlpert Medical School of Brown University
OverviewOverview
Case basedCase based Presentation of illnessPresentation of illness
Important questions to askImportant questions to ask ManagementManagement Physical findingsPhysical findings Work upWork up SummarySummary
Pediatric SeizuresPediatric Seizures
Most common neurologic disorder in Most common neurologic disorder in childhoodchildhood
4-6% of all kids will have 1 seizure before 4-6% of all kids will have 1 seizure before 16y/o16y/o
5 year old female 5 year old female GTC seizureGTC seizure Started 15 minutes agoStarted 15 minutes ago
T-101, P-155, RR-40, BP-110/80, Ox Sat-89%T-101, P-155, RR-40, BP-110/80, Ox Sat-89%
What would you like to do? What would you like to do?
What history do you want to know?What history do you want to know?
Case One
Useful History for SeizureUseful History for Seizure Does s/he have a fever?Does s/he have a fever? Does s/he have a seizure disorder?Does s/he have a seizure disorder?
If yes, is s/he on anti-seizure meds?If yes, is s/he on anti-seizure meds? If yes, is s/he taking them, or any recent If yes, is s/he taking them, or any recent
changes?changes? Any trauma?Any trauma? Any medicines s/he had access to?Any medicines s/he had access to? How was s/he before the seizure started?How was s/he before the seizure started? Is s/he developmentally normal?Is s/he developmentally normal? Bottle or breast?Bottle or breast? Did you have a party last night?Did you have a party last night?
PMHx former 27 week’erPMHx former 27 week’er Has a known seizure disorderHas a known seizure disorder On phenobarbOn phenobarb Has a fever and is seizingHas a fever and is seizing
Case One
Oxygen, NPAOxygen, NPA
Ask for IV access and d-stickAsk for IV access and d-stick
Ask to draw up Benzo (or phenobarb)Ask to draw up Benzo (or phenobarb)
Getting startedGetting started
Case One
Seizure IV Medication Seizure IV Medication DosagesDosages
LorazepamLorazepam
DilantinDilantin PhenobarbitalPhenobarbital Valproic AcidValproic Acid
0.1mg/kg0.1mg/kg
20mg/kg20mg/kg20mg/kg20mg/kg
20mg/kg20mg/kg
I ain’t got no…I ain’t got no…IV access...IV access...
LorazepamLorazepam 0.1mg / kg IM0.1mg / kg IM Diazepam Diazepam 0.5mg / kg PR0.5mg / kg PR 0.1mg / kg IM0.1mg / kg IM MidazolamMidazolam 0.5mg / kg IM0.5mg / kg IM
0.2mg / kg Intranasal0.2mg / kg Intranasal 0.15mg / kg PR0.15mg / kg PR
FosphenytoinFosphenytoin 20 PE/ kg IM20 PE/ kg IM
Seizure StopsSeizure Stops
What would you like to know and do?What would you like to know and do?
Case One
Chem 7 Chem 7 WNLWNL CBC CBC WBC – 22K WBC – 22K
(60 seg, 30 lymph, 10 (60 seg, 30 lymph, 10 mono)mono)
H/H – 15/45H/H – 15/45
PLT – 600KPLT – 600K U/A U/A normalnormal
Phenobarb level -5 (therapeutic 15-40)Phenobarb level -5 (therapeutic 15-40)
Case One
16 month old female was sleeping in bed 16 month old female was sleeping in bed with parents when they heard a cry and then with parents when they heard a cry and then noticed she was stiff and arms jerking. She noticed she was stiff and arms jerking. She was seizing for 5 minutes.was seizing for 5 minutes.
Brought to ED Brought to ED
VS T-102, P-145, RR-25, BP-90/60, Ox Sat-VS T-102, P-145, RR-25, BP-90/60, Ox Sat-98%98%
Case Two
After antipyretic running around smilingAfter antipyretic running around smiling
VS T-98, P-80, RR-20, BP-85/60VS T-98, P-80, RR-20, BP-85/60
PE – normal examPE – normal exam
What do you want to do?What do you want to do?
What do you tell the family?What do you tell the family?
Case Two
Febrile SeizuresFebrile Seizures
SimpleSimple GeneralizedGeneralized Less than 15-20 minutesLess than 15-20 minutes One in 24 hour periodOne in 24 hour period
ComplexComplex Anything that is not simple Anything that is not simple
Febrile SeizuresFebrile Seizures
6 months to 6 years6 months to 6 years 2-5 % of kids have a febrile seizure2-5 % of kids have a febrile seizure 33% will have a second33% will have a second 10% will have 3 or more10% will have 3 or more No proven increase risk of epilepsy in No proven increase risk of epilepsy in
“normal” kids“normal” kids
Simple Febrile SeizuresSimple Febrile Seizures Work-upWork-up
Find source of fever and treat itFind source of fever and treat it
If you think they have meningitis tap themIf you think they have meningitis tap themLow threshold to tap kids less than 12 Low threshold to tap kids less than 12
monthsmonths
Complex Febrile SeizuresComplex Febrile Seizures Work-upWork-up
Find source of fever and treat itFind source of fever and treat it Work up for seizure Work up for seizure
Febrile SeizuresFebrile SeizuresAntipyretics (what do you tell parents?)Antipyretics (what do you tell parents?)
Worth giving, but no study shows you Worth giving, but no study shows you can prevent future febrile seizurescan prevent future febrile seizures
6 month old female, brought in by rescue. 6 month old female, brought in by rescue. Mother called and felt the child was having Mother called and felt the child was having trouble breathing. trouble breathing.
Seizing, GTC activitySeizing, GTC activity
T-95, P–180, RR–40, BP–80/50, Ox Sat–T-95, P–180, RR–40, BP–80/50, Ox Sat–95%95%
What would you like to know and do?What would you like to know and do?
Case Three
PEPE No sign of traumaNo sign of trauma Fontanelle flatFontanelle flat No rashesNo rashes Rhythmic jerking of arms bilaterallyRhythmic jerking of arms bilaterally Eyes rolled backEyes rolled back Not respondingNot responding
Case Three
Oxygen, NPA Oxygen, NPA Saturation 100% Saturation 100% IV access IV access nice work! nice work! D-stick D-stick 100 good to know Lorazepam 0.1mg/kg X 2 doses Lorazepam 0.1mg/kg X 2 doses thank thank
you!you!
Still seizing???Still seizing???
Case Three
Oxygen, NPA Oxygen, NPA Saturation 100% Saturation 100% IV access IV access nice work! nice work! D-stick D-stick 100 good to know Lorazepam 0.1mg/kg X 2 doses Lorazepam 0.1mg/kg X 2 doses thank thank
you!you!
Still seizing???Still seizing???
Case Three
Na – Na – 119119 K- 4K- 4 Cl – 100Cl – 100 CO2 – 23CO2 – 23 Bun – 15Bun – 15 Cr – 0.3Cr – 0.3 Glu - 120Glu - 120
Case ThreeLABS
If HyponatremicIf Hyponatremic
If less than 125mEq/l and seizingIf less than 125mEq/l and seizing
3%NS3%NS 3cc/kg3cc/kg
Repeat with the goal to get up to 125 mEq/l Repeat with the goal to get up to 125 mEq/l which should stop seizureswhich should stop seizures
Hypothermia(<36.5 or 97.7), bottle fed, seizingHypothermia(<36.5 or 97.7), bottle fed, seizing check Na+check Na+
4 month old brought in by mom, seizing. She 4 month old brought in by mom, seizing. She says she went to check on him and he was says she went to check on him and he was shaking all over. Tried to give him a bath shaking all over. Tried to give him a bath because she thought he was cold but still because she thought he was cold but still shaking.shaking.
T-99.1, P-170, RR-25, BP-110/80, Ox sat-89%T-99.1, P-170, RR-25, BP-110/80, Ox sat-89%
What physical findings would you look for?What physical findings would you look for?
Case Four
Physical (obviously complete exam including)Physical (obviously complete exam including) ““Is the baby seizing?”Is the baby seizing?” Signs of infectionSigns of infection
Fever or hypothermiaFever or hypothermia Signs of traumaSigns of trauma OrganomegalyOrganomegaly Dysmorphic featuresDysmorphic features
Big head, little head, VP shuntBig head, little head, VP shunt Skin findingsSkin findings
Physical Findings to Look ForPhysical Findings to Look For
NeurofibomatosisNeurofibomatosis
If you see these…..
Think about these….
Order one of these…..
Port-wine StainPort-wine StainSturge-WeberSturge-Weber
leptomeningeal angioma
Hyperpigmentation, virilizationHyperpigmentation, virilizationAddison’s, CAHAddison’s, CAH Hyponatemia, hyperkalemia, hypoglycemiaHyponatemia, hyperkalemia, hypoglycemia
What the ??????
Nice tan???
Ash Leaf Macules – Ash Leaf Macules – Tuberous SclerosisTuberous Sclerosis
PEPE Anterior fontanelle bulgingAnterior fontanelle bulging Pupils are minimally reactivePupils are minimally reactive CV – RRRCV – RRR Resp – CTA Bilat, but shallow breathsResp – CTA Bilat, but shallow breaths Abd – distendedAbd – distended Ext – bruising on the armsExt – bruising on the arms Neuro – eyes deviated to right, Neuro – eyes deviated to right,
increased tone, seizingincreased tone, seizing
Case Four
Case Four
Case Four
What do you want to do?
Airway (if not already intubated)Airway (if not already intubated) Fosphenytoin or phenobarbFosphenytoin or phenobarb Mannitol (is BP adequate?)Mannitol (is BP adequate?) Nearest pediatric neurosurgeonNearest pediatric neurosurgeon
Any other children at home?Any other children at home? Document the story well!!Document the story well!!
Case Four
7 year old was at home working on his 7 year old was at home working on his computer and parents heard a thump, computer and parents heard a thump, they ran upstairs and found him they ran upstairs and found him seizing. seizing.
Lasted 2 minutes, he was tired for 30 Lasted 2 minutes, he was tired for 30 minutes and now back to baselineminutes and now back to baseline
What would your work up be?What would your work up be?
Case Five
If If normal examnormal exam and and no significant PMHxno significant PMHx
Will need outpatient EEG, outpatient neurologyWill need outpatient EEG, outpatient neurology Possibly an MRI of brainPossibly an MRI of brain
No Head CT No Head CT (some say 1/1000 mortality for each pediatric head (some say 1/1000 mortality for each pediatric head
CT)CT)
No Blood workNo Blood work
Case Five
Who gets a scan?Who gets a scan?
Focal seizureFocal seizure Persistent seizurePersistent seizure Focal neurological deficitFocal neurological deficit VPSVPS Neurocutaneous disorderNeurocutaneous disorder Signs of increased ICPSigns of increased ICP History of traumaHistory of trauma ImmunocompromisedImmunocompromised Bleeding disorder (sickle cell, hyper or Bleeding disorder (sickle cell, hyper or
hypocoagulable)hypocoagulable)
Who gets labs?Who gets labs?
Bedside glucose:Bedside glucose: Think about it oftenThink about it often
Electrolytes for:Electrolytes for: Prolonged or persistent seizuresProlonged or persistent seizures Younger than 6 months oldYounger than 6 months old History of metabolic disorder, diabetes, History of metabolic disorder, diabetes,
dehydration, excess water intake, altered LOCdehydration, excess water intake, altered LOC
Who gets labs?Who gets labs?
Tox screen if altered LOCTox screen if altered LOC
CSF for:CSF for: neonatal seizuresneonatal seizures altered LOC, prolonged postictal periodaltered LOC, prolonged postictal period signs of meningitissigns of meningitis
Rescue arrives with a 2 year old seizing. Rescue arrives with a 2 year old seizing. Parents woke up and found the child in the living Parents woke up and found the child in the living room on the floor seizing. room on the floor seizing.
T-98, P-160, RR-40, BP-80/50, Ox Sat-92%T-98, P-160, RR-40, BP-80/50, Ox Sat-92%
There was a party the night beforeThere was a party the night before
You get one lab test what is it and why?You get one lab test what is it and why?
Case Six
the parents did not clean up the mixed the parents did not clean up the mixed drinks laying around the house.drinks laying around the house.
Case Six
Maybe Miller had a Miller!Maybe Miller had a Miller!
D-stick 35D-stick 35
Case Six
If HypoglycemicIf Hypoglycemic
Dextrose Dextrose (0.25-1 g/kg)(0.25-1 g/kg) D5NS D5NS 10cc/kg10cc/kg D10NSD10NS 5 cc/kg5 cc/kg 5050 D25NSD25NS 2cc/kg2cc/kg
Remember to start an infusionRemember to start an infusion
The Basics as always….The Basics as always…. AirwayAirway
Oxygen (non rebreather)Oxygen (non rebreather) NP airwayNP airway PositioningPositioning
Breathing Breathing remember cricoid pressure if BVMremember cricoid pressure if BVM
CirculationCirculation Fluids if needed (NS)Fluids if needed (NS)
D,D,D,D duhhhhhh…D,D,D,D duhhhhhh…Dextrose …..check d-stickDextrose …..check d-stick
AccessAccess Three attempts at IVThree attempts at IV
Consider other routesConsider other routes Think IM, PR, intranasalThink IM, PR, intranasal
IM LorazepamIM Lorazepam IM, PR, Intranasal MidazolamIM, PR, Intranasal Midazolam PR Diazapam (Diastat)PR Diazapam (Diastat)
Agree on a weight and ask for meds earlyAgree on a weight and ask for meds early Broslow? Other routine? Broslow? Other routine? Not the best time to be practicing Not the best time to be practicing
multiplicationmultiplication
Additional PearlsAdditional Pearls
Pyridoxine (Vit B6)Pyridoxine (Vit B6)
Consider for persistent seizures in patient Consider for persistent seizures in patient <1 yr<1 yr 50-100 mg IV50-100 mg IV
Consider in suspected Isoniazid toxicityConsider in suspected Isoniazid toxicity Initial dose 70mg/kgInitial dose 70mg/kg
FosphenytoinFosphenytoin
Nicer to veinsNicer to veins Can be infused rapidly with less Can be infused rapidly with less
hypotensionhypotension 20 Phenytoin equivalents/kg load20 Phenytoin equivalents/kg load
4 day old is brought into your ED for poor 4 day old is brought into your ED for poor feeding. You notice this……..feeding. You notice this……..
VS T-99, P-165, RR-35, BP-70/45, Ox Sat VS T-99, P-165, RR-35, BP-70/45, Ox Sat 99%99%
Case Seven
PEPE No sign of traumaNo sign of trauma No rashesNo rashes Well hydratedWell hydrated No dysmorphic featuresNo dysmorphic features Normal toneNormal tone Eyes deviated to the leftEyes deviated to the left Persistent lip smacking/sucking/chewingPersistent lip smacking/sucking/chewing
What would you like to do?What would you like to do?
Case Seven
Neonatal SeizuresNeonatal Seizures Rare to have GTC movementsRare to have GTC movements
Immature cortical developmentImmature cortical development Can be subtle focal findingsCan be subtle focal findings
Repetitive movementsRepetitive movementsEye blinkingEye blinkingEye deviationEye deviationChewingChewingLip smackingLip smackingBicyclingBicycling
Neonatal SeizuresNeonatal Seizures
Can be focal tonic or clonic seizuresCan be focal tonic or clonic seizures
Sustained posturing of one or more Sustained posturing of one or more extremitiesextremities
Possibly just rhythmic jerking of single Possibly just rhythmic jerking of single extremityextremity
Na – 140Na – 140 K - 4K - 4 Cl – 98Cl – 98 CO2 – 24CO2 – 24 Bun – 16Bun – 16 Cr – 0.4Cr – 0.4 Glu - 110Glu - 110
Ca – 7Ca – 7 Mg – 1.1Mg – 1.1 Phos - 2Phos - 2
Case SevenLABS
HypocalcemiaHypocalcemia
Serum calcium Serum calcium < 7-8 mg/dl< 7-8 mg/dl 10% CaGluconate10% CaGluconate 1-2 ml/kg slow IV 1-2 ml/kg slow IV
infusioninfusion 10% CaCl10% CaCl 0.2ml/kg slow IV 0.2ml/kg slow IV
infusioninfusion Continuous ECG monitoringContinuous ECG monitoring
Chest x-ray looking for thymusChest x-ray looking for thymus
No thymus, big heartNo thymus, big heart
DiGeorge Syndrome Microdeletion of chromosome 22Microdeletion of chromosome 22
Low set earsLow set earsHypertelorisHypertelorismmMicrognathiaMicrognathiaFish MouthFish Mouth