Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of...
Transcript of Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of...
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Pediatric Seizures
Michael Kim, MD
Department of Emergency Medicine
University of Wisconsin- Madison
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objectives
• Know seizure language
• Know seizure types
• Learn evaluation
• Learn evidenced intervention
• Learn events in the ED
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Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
4. Postictal period
5. Status epilepticus
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
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Match game
1. Seizure A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 6: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/6.jpg)
Match game
1. Seizure A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 7: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/7.jpg)
Match game
1. Seizure
2. Epilepsy
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 8: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/8.jpg)
Match game
1. Seizure
2. Epilepsy
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 9: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/9.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 10: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/10.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 11: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/11.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
4. Postictal period
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 12: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/12.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
4. Postictal period
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 13: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/13.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
4. Postictal period
5. Status epilepticus
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 14: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/14.jpg)
Match game
1. Seizure
2. Epilepsy
3. Febrile seizure
4. Postictal period
5. Status epilepticus
A. Most common seizure type in
children
B. Sz more than 5 minutes
C. Period of decreased mental
status after seizure
D. Uncontrolled brain electrical
activity
E. Medical condition in a patient
that cause recurrent sz
![Page 15: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/15.jpg)
Seizure classification
(focal)
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Febrile Seizures
• Most common pediatric seizure
• 2-5% children
• Mechanism?
• High risk if under or no immunization
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More facts
• 4-8 per 1000 children < age of 6
• 3-5 % children has 1 episode by 5 yrs
• 30% with additional sz
• 3-6 % of those will have epilepsy
• Most seizures are self limited!
• Require medical evaluation for source
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Status epilepticus
• Continuous sz > 5 min
• Worse outcome with > 30 min sz
• H/o epilepsy risk factor
• Higher long term morbidity
• Mortality 2-5 %
• Need immediate sz cessation intervention
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Children with history of sz
• Likely medication related
• Parents or caregivers are familiar with sz
• Special needs patients (at risk)
• Need medical evaluation
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Causes
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Causes
• Provoked
– Infection
– Trauma (consider NAT)
– Metabolic
– Toxic exposure
– Fever
– Vascular
– Oncologic
• Unprovoked
• <20% identifiable
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Causes
• Provoked
– Infection
– Trauma (consider NAT)
– Metabolic
– Toxic exposure
– Fever
– Vascular
– Oncologic
• Unprovoked
• <20% identifiable
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Clinical Findings in Sz
• Changes in behavior
• Stiffening
• Loss of tone
• Abnormal eye movements/eye
deviation
• Drooling/frothing
• Rhythmic twitching or jerking
• Bitter /metallic taste
• Purposeless movements
• Eye lid fluttering
• Sudden fall(s)
• Teeth clenching
• Temporary stop in breathing
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Important Sz History
• Warning signs
• Head/eyes/lips/tongue
• Start location and progression
• Consciousness
• Duration
• Apnea, loss of bladder and bowel
• Events after the Sz
• Back to baseline
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Other history
• Known risk factors or
• Other medical conditions
• Recent symptoms
• Developmental history
• Medications/toxin exposures
• Family history
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Brief but complete exam
• Mental status
• Vital signs
• Complete head to toe examination
• Comprehensive neuro exam
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Intervention goals
• PAT and ABCDEFG
• Protect and no harm to patient
• Stop the seizure
• Reassure yourself and family
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Shah et al. (2014). An
evidence-based guideline for
pediatric prehospital seizure
management using grade
methodology. Prehospital
Emergency Care,
18(SUPPL.1), 15-24. DOI:
10.3109/10903127.2013.844
874
Intervention approach
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Shah et al. (2014). An
evidence-based guideline for
pediatric prehospital seizure
management using grade
methodology. Prehospital
Emergency Care,
18(SUPPL.1), 15-24. DOI:
10.3109/10903127.2013.844
874
![Page 30: Pediatric Seizures - Home | UW Health€¦ · Pediatric Seizures Michael Kim, MD Department of Emergency Medicine University of Wisconsin- Madison. objectives • Know seizure language](https://reader033.fdocuments.us/reader033/viewer/2022042915/5f52946ad2faa84ed97804d1/html5/thumbnails/30.jpg)
Recommendation: initial
intervention (ABC first)• If seizing, check Glucose
• Capillary versus venous
• If < 60, dextrose IV or Glucagon IM if <60
• Transport if < 60
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Recommendation: intervention
• If Glu > 60 & still seizing, Versed buccal/IN
• Need for IV
• If IV
– Valium* or Ativan at 0.05-0.1 mg/kg IV
– Versed at 0.1 mg/kg IV
• Allow Tx without on line direction if status
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Buccal administration
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IO versus IV
• Time to skin
– 12.7 vs 24.9 sec
• Vascular access time
– 16.9 vs 62.7 sec
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Postictal state
• 5-30 minutes after sz
has stopped
• Drowsiness
• Confusion
• Nausea
• HTN
• HA
• disorientation
• Todd’s paralysis
• Subclinical seizure
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Is the patient still seizing?
(Non-convulsive status)
• Stiffness
• abnormal resp
• Non-variable heart rate
Consider treatment
• Follow protocol
• If long transport time
• If ABC are stable
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Helping parents
• Explain seizure versus epilepsy
• Seizure ≠ epilepsy ≠ intellectual disability
• Information on what to do if sz again
• Support and assist process all info
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Additional work up in the ED
• Sz cessation:
ABCDEF
• Full evaluation for
source
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Additional work up in the ED
• Sz cessation:
ABCDEF
• Full evaluation for
source
– Blood work
– Urine tests
– Imaging
– Spinal tap
– EEG
• Anti-seizure meds
• Admit
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Take home points
• Most are brief and benign
• PAT and ABCDEFG
• If in status, need immediate cessation
• Know recommendation / protocol
• Most need ED evaluation
• Search for etiology
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References
1. Shah et al. (2014). An evidence-based guideline for pediatric prehospital
seizure management using grade methodology. Prehospital Emergency
Care, 18(SUPPL.1), 15-24. DOI: 10.3109/10903127.2013.844874
2. Sources: http://pediatrics.aappublications.org/content/127/2/389.f ull.pdf and
http://pediatriccare.solutions.aap.org/chapter.aspx?sectio
nId=56754849&bookId=1017&resultClick=1#56780691
3. Suyama J, Knutsen CC, Northington WE, Hahn M, Hostler D. IO versus IV
access while wearing personal protective equipment in a hazmat scenario.
Prehosp Emerg Care.2007;11(4):467-472.
4. CNS Drugs. September 2015, Volume 29, Issue 9, pp 741–757| Cite as
A Common Reference-Based Indirect Comparison Meta-Analysis of Buccal
versus Intranasal Midazolam for Early Status Epilepticus
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Thomas 1970
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Types of seizures
• Partial: affects part of the brain
– Simple: focal, but conscious
– Complex: impaired consciousness
• Generalized: whole brain / both
hemispheres
– Convulsive: tonic or clonic
– Nonconvulsive: alteration in consciousness
(petit mal, now called absence)
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Cases and causes
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Sub therapeutic medication
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Case 1
• 5 mo old boy had 10 minute seizure
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Medication non-
compliant
ED events
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Case 2
• 2 year old boy with ear infection had 3
minute tonic clonic seizure
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Medication non-
compliant
ED events
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Case 3
• 5 YO boy while getting ready for bed had a
5 minute Tonic Clonic Sz
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Medication non-
compliant
ED events
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Case 4
• 5 yo girl with diabetes had 3 minute sz
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Medication non-
compliant
ED events
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Mucosal Atomizer Device
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Case 5
• 15 YO with known seizure disorder on
keppra had 7 min typical seizure
A. Hypoglycemia
B. Trauma
C. Idiopathic
D. Febrile
E. Medication non-
compliant
ED events