Office Emergencies: Seizure Review

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Office Emergencies: Seizure Review

  1. 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. 2. Objective #1 A kid is seizing in clinic. What do I do?
  3. 3. ABC’s + D + call for help
  4. 4. ll Pre-hospital Pediatric Seizure Care Guidelines Follow This Sequence Initial Medical Care/Assessment Protect Child From Injury Vomiting and Aspiration Precautions
  5. 5. Head-tilt, chin liftJaw thrust
  6. 6. The Recovery Position
  7. 7. Objective #2 Wait, can you review seizure classifications real quick?
  8. 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. 9. Clinical Presentations That Can Mimic Seizures Apea Breath Holding Dizziness Myoclonus Pseudoseizures Rigors Syncope Tics Strokes
  10. 10. Objective #3 This kid’s seizures are not stopping. I’m freaking out.
  11. 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. 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. 13. Riviello JJ et al. Neurology. 2006 Status Epilepticus: Types, Incidence, & Description
  14. 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. 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. 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. 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. 18. Objective #4 What do I do with febrile seizures?
  19. 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. 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. 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. 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. 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. 24. Objective #5 This kid seized for the first time but looks great now. Do I really have to call neurology?
  25. 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. 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. 27. Prehospital Assessment Monitor ABCDs Position with C-Spine protection (if trauma) Observe and transfer to ED if necessary
  28. 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. 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

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