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Transcript of Status epilepticus the paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief,...
![Page 1: Status epilepticus the paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children.](https://reader035.fdocuments.us/reader035/viewer/2022070411/56649f575503460f94c7b7ec/html5/thumbnails/1.jpg)
Status epilepticusthe paeds emerg perspective
Stephen C. Porter MD MPH MScDivision Chief, Pediatric Emergency Medicine
The Hospital for Sick ChildrenAssociate Professor of Paediatrics
University of Toronto School of Medicine
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Outline for today
• Definitions• ABCDs and parallel processing• The pathway for status epilepticus at The
Hospital for Sick Children• Scientific and artful considerations
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Video tells the story
• http://www.youtube.com/watch?v=aL1cZqmkC4A&feature=related
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Definition of status epilepticus
• The International Classification of Epileptic Seizures defines status epilepticus as a seizure that lasts for a sufficient length of time (30 minutes or longer) or is repeated frequently enough that the individual does not regain consciousness between seizures
• Outcomes are worse for children with more prolonged seizures – early treatment is key
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ABCDs for status
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Airway and breathing
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Circulation and access
• Timely IV placement• Alternatives
– IO– Rectal– Intranasal– Intramuscular
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?Is the serum glucose low?Is there fever?Are there abnormal chemistries?Are there focal neurologic
findings?
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?Is the serum glucose low?Is there fever?Are there abnormal chemistries?Are there focal neurologic
findings?
![Page 10: Status epilepticus the paeds emerg perspective Stephen C. Porter MD MPH MSc Division Chief, Pediatric Emergency Medicine The Hospital for Sick Children.](https://reader035.fdocuments.us/reader035/viewer/2022070411/56649f575503460f94c7b7ec/html5/thumbnails/10.jpg)
Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?
Does the child have a known seizure disorder?
Is the serum glucose low?Is there fever?Are there abnormal chemistries?Are there focal neurologic
findings?
• Are anticonvulsant levels sub-therapeutic?
• Obtain drug levels as indicated
• Is it a breakthrough seizure due to inter-current illness?
• Evaluate for infection
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?
Is the serum glucose low?Is there fever?Are there abnormal chemistries?Are there focal neurologic
findings?
Hypoglycemic seizureDextrose 0.25 – 1 g/kg
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?Is the serum glucose low?
Is there fever?Are there abnormal chemistries?Are there focal neurologic
findings?
• Source of infection, in particular meningitis
• Screening labs• Need for LP?• Empiric antibiotics after
blood/urine obtained?
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?Is the serum glucose low?Is there fever?
Are there abnormal chemistries?
Are there focal neurologic findings?
Electrolyte disturbanceUremiaHepatic failureMetabolic derangementIngestion
Serum chemistries, kidney function, ammonia
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Rapid assessment and treatment
For a child presenting in status epilepticus
Are there signs of trauma?Does the child have a known
seizure disorder?Is the serum glucose low?Is there fever?Are there abnormal chemistries?
Are there focal neurologic findings?
Mass lesionStrokeBrain abscess
CT scan of head
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Pathway of care for status epilepticus
• Treatment should start when a seizure continues longer than 5 minutes
• Continuous cardio-respiratory monitoring is essential. • If IV access fails, consider other routes of delivery• Fosphenytoin is generally preferred for the initial loading
dose over phenytoin or phenobarbital.• If a patient is on phenytoin maintenance, consider
phenobarbital for the initial loading dose• Most common errors
– Using too low of a dose for a benzodiazepine – Delay in initiating second line treatment
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The first 10 minutes
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10 minutes 30 minutes
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Refractory status
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Scientific and artful – intranasal meds
• Draw up the calculated dose of midazolam PLUS an additional 0.1mL (for priming) into a 1mL syringe
• Attach atomizer (MAD Device) to the 1mL syringe
• Prepare atomizer by slowing priming (expelling air via the atomizer) the additional 0.1mL of midazolam
• Position patient either sitting up at minimum of 45 degrees
• Administer dose by inserting atomizer into nostril loosely and aim for the center of the nasal cavity
• Doses with a volume greater than 0.5mL should be split between both nostrils to prevent loss of solution
• Depress plunger quickly
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Scientific and artful – risk of meningitis
• There is an association between prolonged, focal or recurrent seizures and meningitis
• Nigrovic et al validated and published a clinical prediction rule stratifying risks for bacterial meningitis among children with CSF pleocytosis; seizure was the only clinical predictor
• A child with a simple febrile seizure who recovers to a normal mental status with a normal neurologic exam and who is otherwise well is not at risk of meningitis
• A child with a complex febrile seizure who recovers to a normal mental status with a normal neurologic exam and who is otherwise well is at very low risk of meningitis
• For a child in status epilepticus who is febrile, obtain blood cultures and treat with empiric doses of antibiotics
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CFS by feature.
Kimia A et al. Pediatrics 2010;126:62-69
©2010 by American Academy of Pediatrics
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Rates of CSF pleocytosis among patients with a CFS.
Kimia A et al. Pediatrics 2010;126:62-69
©2010 by American Academy of Pediatrics
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Summary
• Doing the right thing for status epilepticus– Emphasis on ABCDs (bag mask skills)– Parallel processing: treat and diagnose– Correct drugs in timely manner in right sequence
• Benzodiazepine (times two)• Second line agent (usually fosphenytoin)
– System readiness to deliver a pathway of care