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Office Emergencies: Seizure Review

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  • Children 2 to 5 years: 0.5 mg/kg
    Children 6 to 11 years: 0.3 mg/kg
    Children ≥12 years and Adults: 0.2 mg/kg
    Note: Round dose to the nearest 2.5 mg increment, not exceeding a 20 mg/dose;

    Gel, Rectal:
    Diastat AcuDial: 10 mg (1 ea); 20 mg (1 ea)
    Diastat Pediatric: 2.5 mg (1 ea) [contains alcohol, usp]
    Generic: 2.5 mg (1 ea); 10 mg (1 ea); 20 mg (1 ea)
  • Remember: Seizure activity cannot be interrupted with verbal or physical stimulation
    Repetitive non-purposeful movements
    Staring
    Lip-smacking
    Stiffening of any or all extremities
    Rhythmic shaking of any or all extremities
  • Psychogenic non-epileptic seizures (PNES), also known as non-epileptic attack disorders (NEAD), are events superficially resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy.
    functional MRI has shown in some recent studies to show that they do have a sound neurological basis.
    PNES are triggered by psychological problems, and frequently occur in conversion disorder. It is estimated that 20% of seizure patients seen at specialist epilepsy clinics have PNES
  • 1/25 will have at least one febrile seizure
    1/3 will have another febrile seizure
    The older the child is when they have their first febrile seizure the less likely they’ll have another one
  • in a normal child with a simple febrile seizure the risk for subsequent epilepsy is only slightly above the general population.
    The chance increases with complex febrile seizures and underlying brain abnormalities
  • postictal phase- altered mental status (confusion, drowsiness, nausea) after a seizure. 5-30 mins but can be prolonged after a long seizure.
    Mechanism: neurotransmitter depletion, cerebral blood flow changes
  • If child back to baseline may be ok to asap to neuro for outpatient follow up
    if deeply postictal/not back to baseline, transfer to ER for further evaluation and treatment (imaging, labs (calcium, magnesium, phosphorous, BMP, CBC, urine tox screens, pregnancy test, neuro consult, EEG)
  • The child who is neurologically normal, has no history of neurologic illness, and no evident acute cause for the seizure has a 24 percent risk of a recurrent seizure in the next year, and a 45 percent risk over the next 14 years, according to one large prospective study. The one year recurrence risk increases to 37 percent in children with a prior neurologic injury, and increases to 70 percent in patients who have had two seizures that are separated by at least 24 hours.
  • dollaso@musc.edu
  • Transcript

    • 1. objectives 5 2. Brief seizure review 3. Status epilepticus: the true emergency 4. Febrile seizures: not so bad 5. First unprovoked seizures: also, not so bad 1. Resuscitation basics
    • 2. Objective #1 A kid is seizing in clinic. What do I do?
    • 3. ABC’s + D + call for help
    • 4. ll Pre-hospital Pediatric Seizure Care Guidelines Follow This Sequence Initial Medical Care/Assessment Protect Child From Injury Vomiting and Aspiration Precautions
    • 5. Head-tilt, chin liftJaw thrust
    • 6. The Recovery Position
    • 7. Objective #2 Wait, can you review seizure classifications real quick?
    • 8. Seizure Classification Generalized Partial Complex SimpleBoth hemispheres involved +LOC Types: - Tonic/clonic - Absence - Atonic (drop attacks) - Infantile spasms Impaired consciousness Motor/autonomic sx May generalize Types of symptoms: 1) Motor- head/eye deviation, jerking, stiffening 2) Autonomic- pupil dilation, drooling, pallor, HR/RR changes 3) Somatosensory- smells, alteration of perception No impaired consciousness Can involve motor, autonomic, somatosensory May generalize
    • 9. Clinical Presentations That Can Mimic Seizures Apea Breath Holding Dizziness Myoclonus Pseudoseizures Rigors Syncope Tics Strokes
    • 10. Objective #3 This kid’s seizures are not stopping. I’m freaking out.
    • 11. Status Epilepticus Life Threatening Emergency Seizures that persist without interruption > 5 mins quential seizures without full recovery of consciousness be Millikan D et al. Emerg Med Clin North Am. 2009
    • 12. Status Epilepticus Occurs in kids with epilepsy 9-27% over time Rapid termination of seizure activity protects against neuronal injury Millikan D et al. Emerg Med Clin North Am. 2009
    • 13. Riviello JJ et al. Neurology. 2006 Status Epilepticus: Types, Incidence, & Description
    • 14. Prehospital Assessment Assess ABCs +D x 2 (Dextrose, Disability) Positioning (C-spine protection if trauma): Jaw thrust/head tilt chin lift Recovery position Nasal airway, if needed and available Aspiration precautions Oxygen, Suction
    • 15. Prehospital Assessment Obtain seizure history How long was it? What did it look like? History of previous seizures (PMHx, FHx) Current illness? Trauma/abuse? Length of postictal phase
    • 16. List of current medications Include any antipyretics given (time and dose) Do the parents have any anticonvulsant medications (rectal diazepam)? Have the patients given any anticonvulsant medications (time and dose)? Prehospital Assessment
    • 17. Prehospital Management If actively seizing >5 mins and parent has not given rectal diazepam, administer it Document time and dose Continue O2, suction Follow BLS guidelines (BVM if inadequate oxygenation) Call EMS to transfer to ED Obtain IV/IO access if possible and does not delay definitive care
    • 18. Objective #4 What do I do with febrile seizures?
    • 19. What’s a Febrile Seizure? Caused by increase in core body temp > 100.4F (38C) Threshold of temp which may trigger seizures is unique to each child
    • 20. Febrile Seizure Facts Benign Peak occurrence: between 6 months to 5 years of age May be either simple or complex Accompanied by fever (before, during, after) WITHOUT ANY: CNS infection Metabolic disturbance Underlying structural brain abnormality
    • 21. 2 Types of Febrile Seizures Simple Complex Seizure lasting < 15 mins Generalized Occurs ONCE in a 24 hour period Seizure lasting > 15 mins Focal Occurs MORE THAN ONCE in a 24 hour period
    • 22. Prehospital Assessment 1) Assess ABCs +D x 2 (Dextrose, Disability) 2) Obtain seizure history: How long was it? What did it look like? History of previous seizures (PMHx, FHx) Current illness? Trauma/abuse? Length of postictal phase 3) Get a list of current meds
    • 23. Prehospital Management Monitor ABCDs Position with C-Spine protection (if trauma) Treat fever or underlying source of infection Observe and transfer to ED if necessary
    • 24. Objective #5 This kid seized for the first time but looks great now. Do I really have to call neurology?
    • 25. First Unprovoked Seizure First seizure that occurs WITHOUT an immediate precipitating event Etiology Remote symptomatic: Related to a pre-existing brain abnormality/insult Cryptogenic/idiopathic: no known cause Can present as a: Partial seizure Generalized, tonic-clonic seizure Tonic seizure
    • 26. Prehospital Assessment 1) Assess ABCs +D x 2 (Dextrose, Disability) 2) Obtain seizure history: How long was it? What did it look like? History of previous seizures (PMHx, FHx) Current illness? Trauma/abuse? Length of postictal phase 3) Get a list of current meds
    • 27. Prehospital Assessment Monitor ABCDs Position with C-Spine protection (if trauma) Observe and transfer to ED if necessary
    • 28. Recurrence Risk After First Unprovoked Seizure Majority of children will have few or no recurrences: approximately 10-20% will have additional seizures regardless of therapy Predictors of recurrence include: Abnormal EEG Underlying etiology Abnormal neurologic exams Remote symptomatic- recurrence risk over 2 years is > 50% Cryptogenic/idiopathic- recurrence risk over 2 years is 30-50% Hirtz D et al. Neurology. 2003
    • 29. Don’t Panic. ABCDs is your mantra. Call for help. If actively seizing or postictal place in recovery position. If trauma suspected, place in C-collar and jaw thrust to ensure adequate airway We quickly reviewed seizure classifications. Remember, a lot of other conditions can mimic seizure activity. Verbal and physical stimulation won’t interrupt a seizure. Status epilepticus is a true medical emergency ABCDs, oxygen, suction, recovery position Rectal diastat/IN versed Call EMS Simple febrile seizures need no further work up or evaluation besides treating underlying cause for fever Complex febrile seizures need further evaluation First-time unprovoked seizures may or may not need immediate neurology consultation. ~10% of kids will have another seizure at some point WRAP-UP