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Neurologic Emergencies.ppt
 

Neurologic Emergencies.ppt

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    Neurologic Emergencies.ppt Neurologic Emergencies.ppt Presentation Transcript

    • pediatric neurologic emergencies may 2002 core rounds
    • contents
      • seizures
        • approaches to
          • febrile seizure
          • new onset non-febrile seizure
          • established seizure disorder with recurrence
          • neonatal seizures
          • status epilepticus
        • investigation, treatment, disposition
      • headache
        • discussion (as little evidence to support)
          • migraine treatment
          • imaging indications
    • case 1
      • 2 year old
      • parents “shaking episode” lasting “10 mins”
      • EMS called - child no longer shaking
      • V/S - BP 105/60 HR 100 RR 18 Sat N T39
      • approach?
        • well looking child
          • first event
          • multiple events
        • sick looking child
    • case 2
      • 8 year old
      • parents describe good history for tonic-clonic activity lasting 2 mins
      • 1st event
      • post event confusion - improving
      • in ED - V/S N, N sensorium, N neuro exam
      • otherwise healthy, no meds, no allergies
      • approach?
    • case 3
      • 16 year old
      • known seizure disorder, on phenytoin
      • typical seizure presenting complaint
      • V/S N, neuro N, otherwise looks well
      • approach?
    • case 4
      • 2 week old
      • parents - “doesn’t look right”, “mouth opening and closing”
      • one episode lasting 1 minute
      • child not interested in feeding, sleepy
      • V/S - BP 90/50 HR 130 RR 38 sat N T 37.8
      • otherwise normal exam
      • approach?
    • definitions
      • febrile seizure – NIH defn - event of infancy/childhood, typically between age 3mo and 5yrs, with no evidence intracranial infection or defined cause
      • epilepsy - two or more seizures not provoked by a specific event such as fever, trauma, infection, or chemical change
    • definitions
      • neonatal seizure – in first 28 days of life (typically first few days)
      • status epilepticus
        • seizure lasting >30 mins
          • NB rosen 5-10 mins
        • sequential seizures without regain LOC >30min
    • classification
      • generalized
        • LOC
        • tonic, clonic, tonic-clonic, myoclonic, atonic, absence
      • partial – focal onset
        • simple partial – no LOC
        • complex partial – LOC
        • partial secondarily generalized
      • unclassified
    • etiology
      • infectious
      • metabolic
      • traumatic
      • toxic
      • neoplastic
      • epileptic
      • other
    • differential diagnosis
      • syncope
      • breath holding
      • sleep disorders (eg. narcolepsy)
      • paroxysmal movement disorder
        • tics,tremors
      • migraines
      • psychogenic seizures
    • approach to febrile seizures the numbers
      • epidemiology
        • age 3mo – 5yrs
        • peak age 9-20 mo
        • 2-5% children will have before age 5
        • 25-40% will have family history
        • 80 – 97% simple
        • 3 - 20% complex
    • simple febrile seizure
      • < 15 mins
      • no focal features
      • no greater than 1 episode in 24h
      • neurologically and developmentally normal
    • complex febrile seizure
      • >15 min
        • febrile epilepticus >30min or recurrent without regaining consciousness > 30min
      • focal
      • recurrence within 24h
    • what do parents want to know?
      • recurrence
        • risk recurrence 25-50%
        • risk recurrence after 2 nd – 50%
        • most recurrences within 6-12 mo
          • (20% within same febrile illness)
      • risk of epilepsy
        • 2-3% (baseline 1%)
        • increased in
          • family history of epilepsy
          • abnormal developmental status
          • complex febrile seizure
    • neonatal seizure
      • brief and subtle
        • eye blinking
        • mouth/tongue movements
        • “ bicycling” motion to limbs
      • typically sz’s can’t be provoked/consoled
      • autonomic changes
      • EEG less predictable
    • neonatal seizure
      • etiology
        • hypoxic-ischemic encephalopathy
          • Presents within first day
        • congenital CNS anomalies
        • intracranial hemorrhage
        • electrolyte abnormalities – hypoglycemia and hypocalcemia
        • infections
        • drug withdrawal
        • pyrodoxine deficiency
    • status epilepticus
      • definition
        • deizure lasting >30 mins
          • NB Rosen 5-10 mins
        • sequential seizures without regain LOC >30min
      • mortality in pediatric status epilepticus 4%
      • morbidity may be as high as 30%
    • SE treatment considerations
      • ABC’s
      • brief directed Hx and Px
      • glucose
      • antibiotics/antivirals
        • if meningitis/encephalitis considered
    • SE treatment
      • 1 st line anticonvulsants
        • IV
          • lorazepam 0.1mg/kg
          • diazepam 0.2 mg/kg
          • midazolam 0.2 mg/kg
        • rectal diazepam
          • 2-5 yrs – 0.5 mg/kg
          • 6-11 yrs – 0.3 mg/kg
          • >12 yrs – 0.2 mg/kg
        • IM, intranasal, buccal midazolam
    • SE treatment
      • 2 nd line agents
        • phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min)
        • fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min)
      • 3 rd line agents
        • phenobarbital 20mg/kg @ 100mg/min
        • repeat prn 5-10mg/kg
        • maximum 40 mg/kg or 1 gram
    • refractory SE treatment
      • consider midazolam
        • 0.2 mg/kg bolus
        • then 1-10 mcg/kg/min infusion
      • induce barbiturate coma
        • pentobarbital 5-15 mg/kg @ 25 mg/min
        • then 1-5 mg/kg/hour
      • others
        • valproic acid
        • paraldehyde, chloral hydrate
        • propofol, inhalational anesthesia, paralysis
        • lidocaine
    • approach – stable post sz
      • history
        • pre-seizure
          • what was child doing when attack occurred
          • precipitants – fever, trauma, poisoning, drug/med use
          • aura
        • deizure
          • what movements – incl. eyes
          • how long
          • LOC?
          • consequences – resp distress, incontinence, injury
        • post seizure
          • Post-ictal
    • approach to stable patient
      • physical directed towards
        • systemic disease
        • infection
        • toxic exposure
        • focal neuro signs
    • laboratory
      • blood glucose?
      • electrolytes?
      • magnesium, calcium?
      • anything at all?
      • what about first time seizures? recurrent?
    • laboratory
      • yes if…
        • neonatal
        • abnormal mental status persistent
        • diabetics, renal disease
        • diuretic use
        • dehydration
        • malnourishment
    • laboratory
      • septic work-up (CBC, BC, urine C+S, CXR, LP)
        • as indicated
          • sick child
          • < 12 - 18 mo
      • therapeutic drug levels
      • other
        • ABG
        • toxicologic screen
        • TORCH, ammonia, amino acids in neonate
        • CPK, lactate, prolactin – ?confirm seizure?
    • lumbar puncture
      • patients at greatest risk for meningitis
        • under 18 months of age
        • seizure in the ED
        • focal or prolonged seizure
        • seen a physician within the past 48 hours
      • other indications
        • concern about follow-up
        • prior treatment with antibiotics
      • The American Academy of Pediatrics
          • “ strongly consider” in infants under 12 months of age with a first febrile seizure
    • neuroimaging
      • WHO? which patients?
      • WHAT? CT vs. MRI
        • ultrasound in neonates
      • WHEN? emergent vs. elective
    • ACEP guidelines - >6 yo
      • consensus indication for non-contrast CT
      • first time seizure patients
        • if suspect structural lesion
        • partial onset seizure
        • age > 40
        • no other identified cause
      • recurrent seizure patients
        • change in pattern
        • prolonged post-ictal period
        • worsening mental status
    • neuroimaging
      • predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures
      • Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23
        • retrospective case series
        • predicts CT scan results normal if
          • no underlying high-risk condition
            • malignancy, NCT, recent CHI, or recent CSF shunt revision
          • older than 6 months
          • sustained a seizure of 15 minutes or less
          • no new-onset focal neurologic deficit
        • not prospectively validated
    • emergent EEG?
      • not generally available on emergent basis
      • but consider in..
        • persistent altered mental status (?non convulsive status epilepticus)
        • paralyzed patients
        • pharmacologic coma
    • disposition
      • can be discharged home if
        • single seizure
        • stable, returning to baseline neuro status
        • no underlying condition/cause requiring treatment in hospital
        • arranged follow-up
    • EEG – 1 st non-febrile seizure
      • follow-up EEG
        • within 24h
          • Lancet 1998;352:1007-11
          • improved pick-up 51% vs 34%
          • ? how soon do we get ours ?
        • inter-ictal EEG’s often normal
          • neuro may do sleep deprivation study (provocation)
        • absence epilepsy and infantile spasms are invariably associated with an abnormal EEG
        • spike and wave 3HZ
    • idiopathic seizure
      • recurrence risk stratification
        • normal EEG – 25%
        • abN EEG – 60%
        • 2 nd seizure – 75%
    • neuroimaging
      • MRI superior
      • not emergently available
      • ?defer imaging until follow-up MRI available in low risk patients?
    • treatment
      • correct underlying pathology, if any
      • antipyretics ineffective in febrile seizure
      • anti-epileptic choice often trial and error
          • no anti-epileptic 100% effective
          • febrile seizure – diazepam, phenobarbital, valproic acid
            • Currently AAP does not recommend
          • neonatal - phenobarbital
          • generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid, primidone
          • absence – ethosuximide, valproic acid
          • new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate, tiagabine, vigabatrine
      • in consultation with neurologist
    • pediatric headache
    • case 5
      • 14 year old
      • mother’s chief complaint - “having headaches all the time, getting worse, this is not normal!!” etc. etc……..
      • V/S N
      • looks in discomfort but otherwise well
      • approach?
        • treatment
        • imaging?
    • classification
      • classify based on temporal pattern
      • acute headaches
        • any febrile illness, sinus/dental infection, intracranial infection/bleed (AVM,SAH,trauma)
      • acute recurrent
      • chronic progressive
      • chronic non-progressive
        • tension, psychogenic, post-traumatic, ocular refractive error
    • acute recurrent headache
      • migraine
      • other
        • cluster headache – typically >10 yo
        • sinusitis
        • vascular malformation
    • migraine - terminology
      • classic migraine
        • biphasic
          • neuro aura
          • headache, N/V, anorexia, photophobia
        • either unilateral (older) / bilateral(younger) or both
      • common migraine
        • malaise, dizziness, N/V, feels and looks sick
        • unilateral/bilateral
      • migraine equivalent/”complicated migraine”
        • transient neuro deficits
        • +/- headache
      • migraine variants
        • Cyclic N/V, abdo pain
        • BPV
    • migraine treatment
      • very little supporting evidence for pharmacologic treatment in children compared to adults
      • classes of medication
        • acetaminophen
        • NSAIDS
        • phenothiazines (dopamine antagonists)
        • dihydroergotamine
        • triptans
    • the simple stuff
      • acetaminophen 15 mg/kg PO 30mg/kg PR
      • ibuprofen 10 mg/kg PO
      • Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover study
      • Neurology 48:103-107, 1997
        • N = 88 age 4-16
        • relief at 2 hours
          • acetaminophen 54%
          • ibuprofen 68%
    • other NSAIDS
      • naproxen 5-7 mg/kg PO
        • no pediatric evidence
      • ketorolac IV 0.5 mg/kg (max 30mg dose)
        • not studied in pediatric migraine
        • not approved <16 yo
        • Houck CS – Safety of intravenous ketorolac in children and cost savings with a unit dosing system . J Pediatr - 01-Aug-1996; 129(2): 292-6
          • 1747 children
          • 0.2% hypersensitivity
          • 0.1% renal complications (in patients with renal disease)
          • 0.05% gi bleed
    • dihydroergotamine
      • not approved
      • ?dose – 0.1 – 0.5 mg IV
      • not studied in emergency population
      • Linder SL – Treatment of childhood migraine with dihydroergotamine mesylate Headache - 1994 Nov-Dec; 34(10): 578-80
        • N = 30
        • inpatient protocol
        • IV DHE and PO metoclopramide – average 5 doses!
        • 80% response
    • phenothiazines
      • again no studies
      • metoclopramide 1-2 mg/kg IV (max 10mg)
      • prochloperazine 0.1 – 0.15 mg/kg IV/IM/PO/PR (max 10mg)
      • children may be more susceptible to EPS
        • ? pre-treat with benadryl
    • triptans
      • mostly studied in adolescent groups
      • sumitriptan subcutaneous 0.06mg/kg
        • Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50 consecutive patients with acute migraine in a pediatric neurology office practice. Headache 36:419–422, 1996
        • N = 50 age 6-18
        • 78% effective at 2 hours
        • 6% recurrence
      • sumitriptan intranasal
        • long term treatment studies done
        • no emergent studies
      • triptans PO
        • studies plagued by high placebo response
    • chronic progressive headache
      • least common presentation
      • most worrisome for increased ICP
        • pseudotumor cerebri
        • space occupying lesion
    • imaging indications? discuss
      • lack of evidence to help
        • small studies lack power to guide decision making
      • MRI preferred in non-urgent indication
    • imaging indications? discuss
      • classically based on historical and physical
        • sudden severe headache
        • rapid increase over days - weeks
        • chronic progressive
        • suggestive of increased ICP
          • severe nocturnal headache (wakes or upon waking), changes in pain with position, coughing
        • following head trauma
        • persistent neuro findings
          • ? include migraine equivalents ?
        • growth abnormality
        • age (? <3 ?)