Shake & bake

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  • 25-40,000 children per year have 1st time unprovoked seizure
  • Epilepsy is defined as 2 or more seizures without acute provocation.
  • Breath-holding spells –
    5-10% of children aged 6 months to 5 years
    no post-ictal phase
    -cyanotic- crying then breath-holding then cyanosis then rigidity then limpness then + twitching
    - pallid – inciting painful stimulus then pallor followed by brief loss of consciousness
    Atypical Migraines - Altered consciousness that may be associated with blurred vision, dizziness and loss of postural tone
    GERD- Sandifer’s syndrome- may present with crying, vomiting and writhing with arching movements of the back and neck
  • Paroxysmal movement disorders involve abnormal motor activity and may mimic seizures; but altered LOC is rare
    Acute dystonia is usually associated with medications
    Pseudoseizures usually have a lack of coordination of movements, moaning or talking during the episode, absence of incontinence or bodily injury, and suggestibility.
    Shuddering attacks are whole body tremors that last a few seconds with rapid return to normal
    Spasmus nutans occurs in children 4-12 months- head tilt, nodding and rapid uncontrolled eye movement, self resolving
    Tics are brief and repetitive and often incited by stress and usually suppressible
    Sleep disorders-
    narcolepsy (may be associated with cataplexy- sudden loss of muscle tone while still conscious
    night terrors
    sleepwalking
    Psychological disorders
    ADHD
    Hyperventilation
    Hysteria
    Panic Attacks
  • We are discussing only first time nonfebrile seizures here
    Pyridoxine: B6, inherited is rare, can get acquired deficiency, present almost exclusively before 3 mo old, usually in the neonatal period
  • Recommendations based on “Practice Parameter: Evaluating a first nonfebrile seizure in children” Report of the Quality Standards Subcommittee of the Amer Acad of Neurology, the Child Neurology Society, and the American Epilepsy Society
    D. Hirtz, et al, Neurology, Sept 2000
    Recommendations are standards, guidelines or options based on evidence available
    seizure types covered by this parameter include partial (simple or complex partial, or partial with secondary generalization), generalized tonic-clonic, or tonic seizures. We are specifically not including children diagnosed with epilepsy, defined as two or more seizures without acute provocation. For this reason, myoclonic and atonic seizures are excluded because they typically are not recognized until there have been multiple occurrences.
    Excluded sz: Children with significant head trauma immediately preceding the seizure or those with previously diagnosed CNS infection or tumor or other known acute precipitating causes are excluded. We excluded neonatal seizures (≤28 days), first seizures lasting 30 minutes or more (status epilepticus), and febrile seizures
  • Turnbull - prospective
  • Separate information –study by Garvey- 65 kids-
    1 positive cocaine screen
    7 electrolyte abnormalities-4 hyponatremia- three had suggestive history
    3 hypocalcemia- 1 clinical rickets, 1 with multiple seizures, one prolonged focal seizure
  • Up to 70% of infants under 6 months may have abnormal electrolytes
    The fact that a first nonfebrile seizure occurred in the absence of any suggestive history or symptoms in a child who is older than age 6 months and has returned to baseline has not been shown to be sufficient reason to perform routine laboratory testing in the child with a first nonfebrile seizure. Keep in mind that all of these studies had small number of children
  • There is no evidence regarding the yield of routine LP following a first nonfebrile seizure. The one study available (Class II) is limited in size and age range. Recommendations based on age and clinical symptoms are available from Class III publications. In the very young child (<6 months), in the child of any age with persistent (cause unknown) alteration of mental status or failure to return to baseline, or in any child with meningeal signs, LP should be performed
  • EEG done within 24 hours of seizure is most likely to show abnormality, but some abnormalities, like postictal slowing may be transient
    The majority of evidence from Class I and Class II studies confirms that an EEG helps in determination of seizure type, epilepsy syndrome, and risk for recurrence, and therefore may affect further management decisions. Experts commonly recommend that an EEG be performed after all first nonfebrile seizures
  • Thus, there is insufficient evidence to support a recommendation at the level of standard or guideline for the use of routine neuroimaging, i.e., imaging performed for which having had a seizure is the sole indication, after a first nonfebrile seizure in children. However, neuroimaging may be indicated under some circumstances either as an emergent or nonurgent procedure.
  • Retrospective chart review- Scottish Rite- Atlanta
    Of the 38 pt with clinically significant imaging 32 were high risk, 6 were low risk
    Low risk = nonfocal seizure and no predisposing conditions
    Low risk patients-
    2 month old with subdural hematoma- had abnormal mental status
    3 year old with anoxic brain injury – presented in status and had abnormal mental status
    9 year old with 5 mm arachnoid cyst – had normal exam – rx’ed with anticonvulsants
    10 year old with benign frontal lobe tumor – had new right sided hemiparesis
    12 year old with grey matter heterotopia – normal exam – rx’ed with anticonvulsants
    16 year old with hypertensive encephalopathy – had 4 seizures and was hypertensive at presentation
  • Thus, there is insufficient evidence to support a recommendation at the level of standard or guideline for the use of routine neuroimaging, i.e., imaging performed for which having had a seizure is the sole indication, after a first nonfebrile seizure in children. However, neuroimaging may be indicated under some circumstances either as an emergent or nonurgent procedure.
  • Based on “Practice parameter: Treatment of the child with a first unprovoked seizure”
    Report of the Quality Standards Subcommittee of the Amer Acad of Neurology and the practice committee of the Child Neurology Society – Neurology, 2003 Hirtz, et al
    Key questions-
    What are potential risks resulting form a second seizure
    How likely is a second seizure
    How likely are multiple recurrences
    are there risk factors that increase recurrence rate
    Are there special considerations if the first seizure is prolonged?
    How effective is treatment in preventing recurrences
    Does treatment change the long term prognosis for remission
    What are the nature and side effects of common AEDS
  • 15- 65 % recurrence risk
    19-26% will have multiple recurrences
    Treatment after 1 seizure decreases risk of recurrence but magnitude of impact is unknown
    Up to 25% of treated pts have significant behavioral or cognitive side effects 7-58% have systemic side effects (rash, hirsuitism, weight gain, abnormal LFTs, etc)
  • Fever 100.4 by any method without CNS infection that occurs in children 6mo-5years of age
    This pracitce guideline is for simple febrile sz not complex feb sz
    Complex febrile sz: focal, >15min, recurred within 24 hrs
  • If one parent had febrile seizures- risk increases 4.4 times
    If both parents have pos. history – increases 20 times
    If sibling had feb seizures- risk increases 3.6 times
  • “lower” = <40 C
  • 2011 recs
    1st-level b, strongly recommended
    2nd-level d (case reports), optional
    3rd-level d, optional (antibiotic tx can mask signs/sx of meningitis)
  • Also, EEG not routinely recommended – consider if devel delayed or underlying neurologic disorder
  • Rare for newborns to have symmetric, generalized tonic clonic sz-the newborns immature nervous system is unable to produce and sustain tonic clonic activity
    Must differentiate from jittery baby or benign myoclonic movements (isolated jerky movement of an extremity that occurs primarily during sleep) jitteryness should stop if extremity is held
    Subtle sz-stereotypical repetitive movements, eye blinking, eye deviation, lip smacking, chewing motions, bicycling/pedaling movements
  • Perinatal hypoxia is MCC seizures in first 3 days of life
    Pyridoxine deficiency- autosomal recessive disorder
    presents first 1-2 days of life
    severe seizures resistant to usual antiepileptic drugs
    treat with pyridoxine – 50 – 100 mg IV
    Benign familial neonatal convulsions- first few days of life
    cause unknown
    strong family history
    resolve by 1 – 6 months of age
    Benign idiopathic neonatal convulsions- 5th day fits
    resolve by day 15
  • Subtle-sterotypical repetitive movements, eye blinking, eye deviation, lip smacking, chewing motions bicycling movements
    Tonic-sustained posturing of a limb
    Clonic-rhythmic jerking of one or more parts of the body, can be focal
    Myoclonic-unlike benign myoclonic jerk myoclonic seizures occur during waking and are single or repetitive rapid jerks, distinguished from clonic by more rapid speed, may lead to infantile spasms
  • Detailed hx-prenatal, perinatal and post natal events
  • Shake & bake

    1. 1. Shake & BakeShake & Bake Evaluation and Management of First Time PediatricEvaluation and Management of First Time Pediatric SeizuresSeizures Tricia Falgiani, MDTricia Falgiani, MD Assistant ProfessorAssistant Professor Department of Emergency MedicineDepartment of Emergency Medicine Division of Pediatric Emergency MedicineDivision of Pediatric Emergency Medicine
    2. 2. ObjectivesObjectives  At the end of this session, the participant willAt the end of this session, the participant will be able to:be able to: – Discuss indications for laboratory andDiscuss indications for laboratory and radiographic studies in a child with first timeradiographic studies in a child with first time afebrile seizure.afebrile seizure. – Discuss indications for testing and treatment of aDiscuss indications for testing and treatment of a child with a febrile seizurechild with a febrile seizure – Discuss the differences in evaluation andDiscuss the differences in evaluation and treatment of the very young infant with first timetreatment of the very young infant with first time seizures.seizures.
    3. 3. First Time SeizuresFirst Time Seizures Who cares?Who cares?  Seizures are the most commonSeizures are the most common pediatric neurologic disorderpediatric neurologic disorder  4 – 6 % of children will have at least4 – 6 % of children will have at least one seizure in the first 16 years of lifeone seizure in the first 16 years of life  The greatest incidence occurs in thoseThe greatest incidence occurs in those under 3 years of ageunder 3 years of age
    4. 4. Seizure DefinitionSeizure Definition  ““A transient, involuntary alteration ofA transient, involuntary alteration of consciousness, behavior, motorconsciousness, behavior, motor activity, sensation, or autonomicactivity, sensation, or autonomic function caused by an excessive ratefunction caused by an excessive rate and hypersynchrony of dischargesand hypersynchrony of discharges from a group of cerebral neurons”from a group of cerebral neurons” Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53Friedman and Sharieff, “Seizures in Children”, Pediatr Clin N Am 53 (2006)(2006)
    5. 5. Pediatric SeizuresPediatric Seizures Differential DiagnosisDifferential Diagnosis  Disorders with altered consciousnessDisorders with altered consciousness – Apnea and syncopeApnea and syncope – Breath-holding spellsBreath-holding spells – Cardiac dysrhythmiasCardiac dysrhythmias – Atypical migrainesAtypical migraines  Gastroesophageal refluxGastroesophageal reflux
    6. 6. Pediatric SeizuresPediatric Seizures Differential DiagnosisDifferential Diagnosis  Paroxysmal movement disordersParoxysmal movement disorders – Acute dystoniaAcute dystonia – Benign myoclonusBenign myoclonus – PseudoseizuresPseudoseizures – Shuddering attacksShuddering attacks – Spasmus nutansSpasmus nutans – TicsTics  Sleep disordersSleep disorders  Psychological disordersPsychological disorders
    7. 7. SeizuresSeizures TreatmentTreatment --Acute StabilizationAcute Stabilization Establish ABCsEstablish ABCs Consider IV glucose, naloxone, or pyridoxineConsider IV glucose, naloxone, or pyridoxine First dose of benzodiazepineFirst dose of benzodiazepine Phenytoin or Fosphenytoin (20 mg/kg IV)Phenytoin or Fosphenytoin (20 mg/kg IV) Phenobarbital (20mg/kg IV)Phenobarbital (20mg/kg IV) reassess, consider intubationreassess, consider intubation Continuous Infusion of BarbiturateContinuous Infusion of Barbiturate intubate nowintubate now General anesthesiaGeneral anesthesia
    8. 8. Nonfebrile SeizuresNonfebrile Seizures Practice ParameterPractice Parameter  Based on recommendations publishedBased on recommendations published in Neurology in 2000in Neurology in 2000  Comprehensive review of 66 articlesComprehensive review of 66 articles  Children 1 month – 21 yearsChildren 1 month – 21 years  1st time seizures not explained by1st time seizures not explained by immediate, obvious, provoking causeimmediate, obvious, provoking cause  Seizure lasting < 30 minutesSeizure lasting < 30 minutes
    9. 9. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation EvidenceEvidence  Eisner, et alEisner, et al – 30 children (0-18) and 133 adults30 children (0-18) and 133 adults – CBC, BMP, Ca, Mg doneCBC, BMP, Ca, Mg done – 1 case of unsuspected hyperglycemia1 case of unsuspected hyperglycemia  Turnbull, et alTurnbull, et al – 136 new onset seizures136 new onset seizures – No clinically significant lab abnormalities in theNo clinically significant lab abnormalities in the 16 children in the study (12-19 years old)16 children in the study (12-19 years old)
    10. 10. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation Evidence, cont.Evidence, cont.  Larger retrospective studies (Nypaver et alLarger retrospective studies (Nypaver et al and Smith et al)and Smith et al) – 507 children total- febrile and nonfebrile seizures507 children total- febrile and nonfebrile seizures – Lab did not contribute to diagnosis orLab did not contribute to diagnosis or managementmanagement  FarrarFarrar – 47 infants < 6 months of age47 infants < 6 months of age – 70% with hyponatremia70% with hyponatremia
    11. 11. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation RecommendationsRecommendations  Laboratory tests should be ordered basedLaboratory tests should be ordered based on individual clinical circumstances thaton individual clinical circumstances that include suggestive historic or clinicalinclude suggestive historic or clinical findingsfindings (think hard about electrolytes in children under 6(think hard about electrolytes in children under 6 months of age)months of age)  Toxicology screening should be consideredToxicology screening should be considered if there is any question of exposure orif there is any question of exposure or substance abusesubstance abuse
    12. 12. Nonfebrile SeizuresNonfebrile Seizures Lumbar PunctureLumbar Puncture  EvidenceEvidence – Rider et alRider et al  57 CSF samples in children with nonfebrile57 CSF samples in children with nonfebrile seizures (2-24 months old)seizures (2-24 months old)  12.3% with >5 leukocytes/mm312.3% with >5 leukocytes/mm3  None with meningitisNone with meningitis  RecommendationRecommendation – Lumbar Puncture is of limited value and shouldLumbar Puncture is of limited value and should only be used if there is clinical concern foronly be used if there is clinical concern for meningitis or encephalitismeningitis or encephalitis
    13. 13. Nonfebrile SeizuresNonfebrile Seizures EEGEEG  EvidenceEvidence – Multiple studiesMultiple studies  EEGs are the best predictors of recurrence in childrenEEGs are the best predictors of recurrence in children who are neurologically normalwho are neurologically normal  Helps determine seizure type, epilepsy syndrome andHelps determine seizure type, epilepsy syndrome and risk of recurrencerisk of recurrence  Optimal timing is not clearOptimal timing is not clear  RecommendationRecommendation – The EEG is recommended as part of theThe EEG is recommended as part of the evaluation of the child with first timeevaluation of the child with first time nonprovoked seizures (nonprovoked seizures (StandardStandard))
    14. 14. Nonfebrile SeizuresNonfebrile Seizures NeuroimagingNeuroimaging EvidenceEvidence  Multiple studiesMultiple studies – Abnormalities found in up to 1/3, but most did not influenceAbnormalities found in up to 1/3, but most did not influence management decisionsmanagement decisions – 2% clinically significant findings2% clinically significant findings Most of those done because of focality of seizure or specificMost of those done because of focality of seizure or specific clinical findingsclinical findings – EmergentEmergent imaging is to detect a serious condition that mayimaging is to detect a serious condition that may require immediate interventionrequire immediate intervention – Non-urgentNon-urgent imaging detects abnormalities that may affectimaging detects abnormalities that may affect prognosis, and thus have an impact on long termprognosis, and thus have an impact on long term managementmanagement
    15. 15. Nonfebrile SeizuresNonfebrile Seizures ImagingImaging  Sharma et alSharma et al – 500 nonfebrile first time seizures500 nonfebrile first time seizures – Mean age 46 months (0 – 21 years)Mean age 46 months (0 – 21 years) – 95% were imaged95% were imaged  91% CT, 4% MRI91% CT, 4% MRI – 83% normal83% normal – 9% clinically insignificant abnormalities9% clinically insignificant abnormalities – 8% (38 pts) clinically significant8% (38 pts) clinically significant  Only 6 patients defined as “low risk”Only 6 patients defined as “low risk”
    16. 16. Nonfebrile SeizuresNonfebrile Seizures ImagingImaging  RecommendationsRecommendations – If neuroimaging is obtained, MRI is preferred modalityIf neuroimaging is obtained, MRI is preferred modality ((guidelineguideline)) – Emergent imagingEmergent imaging should be performed in a child whoshould be performed in a child who exhibits a post-ictal focal deficit not quickly resolving , orexhibits a post-ictal focal deficit not quickly resolving , or who does not return to baseline within several hourswho does not return to baseline within several hours ((optionoption)) – Non-urgent imagingNon-urgent imaging with MRI should be considered in anywith MRI should be considered in any child with a significant cognitive or motor impairment ofchild with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities onunknown etiology, unexplained abnormalities on neurological exam, a seizure of partial (focal) onset, anneurological exam, a seizure of partial (focal) onset, an EEG that does not represent a benign partial epilepsy ofEEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in childrenchildhood or primary generalized epilepsy, or in children under 1 year of age. (under 1 year of age. (optionoption))
    17. 17. Nonfebrile SeizuresNonfebrile Seizures TreatmentTreatment  Practice ParameterPractice Parameter – Defined first seizure to include multipleDefined first seizure to include multiple seizures in a 24 hour periodseizures in a 24 hour period – Excluded seizures with a knownExcluded seizures with a known precipitating causeprecipitating cause – Asked several key questionsAsked several key questions
    18. 18. Nonfebrile SeizuresNonfebrile Seizures TreatmentTreatment  ConclusionConclusion – Majority of children will have few or noMajority of children will have few or no recurrencesrecurrences – Treatment with anti-epileptic drug (AED) afterTreatment with anti-epileptic drug (AED) after first seizure does not improve prognosis for long-first seizure does not improve prognosis for long- term remissionterm remission – Treatment does reduce risk of recurrenceTreatment does reduce risk of recurrence – AED therapy does have potential seriousAED therapy does have potential serious pharmacologic and psychosocial side effectspharmacologic and psychosocial side effects – There is no evidence whether treatment after aThere is no evidence whether treatment after a first afebrile seizure alters risk of suddenfirst afebrile seizure alters risk of sudden unexplained death in epilepsy patientsunexplained death in epilepsy patients
    19. 19. Nonfebrile SeizuresNonfebrile Seizures TreatmentTreatment  Recommendations:Recommendations: – Treatment with AED isTreatment with AED is notnot indicated forindicated for the prevention of the development ofthe prevention of the development of epilepsyepilepsy – Treatment with AEDTreatment with AED may be consideredmay be considered in circumstances where benefits ofin circumstances where benefits of reducing the risk of second seizurereducing the risk of second seizure outweigh the risks of side effectsoutweigh the risks of side effects
    20. 20. Nonfebrile SeizuresNonfebrile Seizures DischargeDischarge  Patient may go home if returns to baselinePatient may go home if returns to baseline – Must be able to follow up with primaryMust be able to follow up with primary – Should have EEG doneShould have EEG done – Neurology follow-upNeurology follow-up – What to tell family:What to tell family:  Sudden death or significant injury is extremelySudden death or significant injury is extremely uncommonuncommon  General safety precautionsGeneral safety precautions  Follow-up EEG recommendedFollow-up EEG recommended
    21. 21. Febrile SeizuresFebrile Seizures  DefinitionDefinition – Any seizure occurring in an infant or young childAny seizure occurring in an infant or young child (6 months – 5 years of age) in conjunction with a(6 months – 5 years of age) in conjunction with a fever or history of recent fever without evidencefever or history of recent fever without evidence of previous seizure or underlying causeof previous seizure or underlying cause – Simple febrile seizures last less than 15 minutes,Simple febrile seizures last less than 15 minutes, are generalized, and occur only once in a 24are generalized, and occur only once in a 24 hour periodhour period
    22. 22. Febrile SeizuresFebrile Seizures  EpidemiologyEpidemiology – 2-5% of children2-5% of children – No racial, geographic or ethnicNo racial, geographic or ethnic differencesdifferences – 25 – 40% have family history of febrile25 – 40% have family history of febrile seizures in first degree relativesseizures in first degree relatives – Etiology is most commonly viralEtiology is most commonly viral – Rate of SBI is same as in children withRate of SBI is same as in children with fever and no seizurefever and no seizure
    23. 23. Febrile SeizuresFebrile Seizures  Risk of recurrenceRisk of recurrence – Higher if:Higher if:  first seizure occursfirst seizure occurs << 15 months of age15 months of age  history of epilepsy or febrile seizure in first degree relativehistory of epilepsy or febrile seizure in first degree relative  many episodes of fevermany episodes of fever  initial seizure is complexinitial seizure is complex – 10% recurrence if no risk factors10% recurrence if no risk factors – 25-50% recurrence if 1-2 risk factors25-50% recurrence if 1-2 risk factors – 50-100% if50-100% if >>3 risk factors3 risk factors – Risk also higher if lower fever when seizure occurs orRisk also higher if lower fever when seizure occurs or shorter duration of fever when seizure occursshorter duration of fever when seizure occurs Knudsen and Berg et alKnudsen and Berg et al
    24. 24. Febrile SeizuresFebrile Seizures  Risk of complex febrile seizuresRisk of complex febrile seizures – Increased if:Increased if:  <12 months old at onset<12 months old at onset  family history of febrile seizuresfamily history of febrile seizures  lower rectal temp during initial seizure (<40 C)lower rectal temp during initial seizure (<40 C) – Offringa et alOffringa et al  Risk of developing epilepsyRisk of developing epilepsy – 1 simple febrile seizure- slightly higher than1 simple febrile seizure- slightly higher than general population (1%)general population (1%) – <12 months at onset- 2-4% risk<12 months at onset- 2-4% risk – Complex seizures – 30 – 50 times risk of generalComplex seizures – 30 – 50 times risk of general pop.pop.
    25. 25. Febrile SeizuresFebrile Seizures Evaluation and managementEvaluation and management  StabilizeStabilize – ABCsABCs – Benzodiazepines first lineBenzodiazepines first line – Phenytoin or phenobarbital secondPhenytoin or phenobarbital second  Good history and physical examGood history and physical exam  Routine labs NOT indicatedRoutine labs NOT indicated – Maybe bedside glucoseMaybe bedside glucose
    26. 26. Febrile SeizuresFebrile Seizures Evaluation and managementEvaluation and management  LP studiesLP studies – GreenGreen  503 patients with meningitis (2 mon – 15 yrs)503 patients with meningitis (2 mon – 15 yrs)  No cases presented as isolated seizureNo cases presented as isolated seizure – Al-EissaAl-Eissa  200 children with fever and seizure200 children with fever and seizure  51% had LP51% had LP  1.5% had bacterial meningitis- all had1.5% had bacterial meningitis- all had complex sz. And most had altered sensoriumcomplex sz. And most had altered sensorium
    27. 27. Febrile SeizuresFebrile Seizures Evaluation and managementEvaluation and management  LP studiesLP studies – Lorber and SunderlindLorber and Sunderlind  15/452 with meningitis- all looked ill or had classic15/452 with meningitis- all looked ill or had classic signs of meningitissigns of meningitis – Joffe et alJoffe et al  11/241 had bacterial meningitis11/241 had bacterial meningitis  All had either:All had either: – Visit to physician within prior 48 hoursVisit to physician within prior 48 hours – Seizure in EDSeizure in ED – Focal seizure ORFocal seizure OR – Suspicious finding on examSuspicious finding on exam
    28. 28. Febrile SeizuresFebrile Seizures Evaluation and managementEvaluation and management  Lumbar Puncture?????Lumbar Puncture????? – 2011 AAP recommendations2011 AAP recommendations  Any child with meningeal signs or hx/PEAny child with meningeal signs or hx/PE suggestive of meningitis (level B)suggestive of meningitis (level B)  Any infant 6-12 mo if deficient inAny infant 6-12 mo if deficient in immunizations (Hib, prevnar) (level D)immunizations (Hib, prevnar) (level D)  Any child that has been treated withAny child that has been treated with antibiotics (level D)antibiotics (level D) – HOWEVER- no documented cases ofHOWEVER- no documented cases of occult bacterial meningitis in patientsoccult bacterial meningitis in patients presenting with simple febrile seizurespresenting with simple febrile seizures alonealone
    29. 29. Febrile SeizuresFebrile Seizures Who to tap…Who to tap…  Strongly consider if less than 18 months old with:Strongly consider if less than 18 months old with: – History of irritability, poor feeding or lethargyHistory of irritability, poor feeding or lethargy – Abnormal appearance or mental status on initial examAbnormal appearance or mental status on initial exam after post-ictal periodafter post-ictal period – Physical signs of meningitisPhysical signs of meningitis – Any complex featuresAny complex features – Slow post-ictal clearing of mentationSlow post-ictal clearing of mentation – Pretreatment with antibioticsPretreatment with antibiotics Warden et al, ”Evaluation and Management of Febrile Seizures in the Out-of-Warden et al, ”Evaluation and Management of Febrile Seizures in the Out-of- Hospital and Emergency Department Settings”, Ann Emerg Med. 2003Hospital and Emergency Department Settings”, Ann Emerg Med. 2003
    30. 30. Febrile SeizuresFebrile Seizures Who to scan…Who to scan…  Routine neuroimaging NOTRoutine neuroimaging NOT recommendedrecommended  Consider urgent imaging if:Consider urgent imaging if: – Unable to clinically exclude increasedUnable to clinically exclude increased intracranial pressure on examintracranial pressure on exam – Status epilepticus or complex featuresStatus epilepticus or complex features – Evidence of traumaEvidence of trauma – Presence of a CSF shuntPresence of a CSF shunt
    31. 31. Febrile SeizuresFebrile Seizures EEG and LabsEEG and Labs  2011 AAP Recommendations2011 AAP Recommendations – EEG should not be preformed inEEG should not be preformed in neurologically normal child with simpleneurologically normal child with simple febrile seizurefebrile seizure – Serum electrolytes, ca, phos, mg, cbc, orSerum electrolytes, ca, phos, mg, cbc, or blood glucose should NOT be performedblood glucose should NOT be performed for the sole purpose of identifying thefor the sole purpose of identifying the cause of a simple febrile seizurecause of a simple febrile seizure
    32. 32. Febrile SeizuresFebrile Seizures DispositionDisposition  Simple febrile seizuresSimple febrile seizures – Home if adequate follow-upHome if adequate follow-up – Anticipatory guidance about the benign nature ofAnticipatory guidance about the benign nature of febrile seizures, recurrence risks and returnfebrile seizures, recurrence risks and return precautionsprecautions  Complex febrile seizuresComplex febrile seizures – May need admission for monitoring and furtherMay need admission for monitoring and further evaluationevaluation – If discharge, arrange follow-up with PCP orIf discharge, arrange follow-up with PCP or neurologist, or bothneurologist, or both
    33. 33. Febrile SeizuresFebrile Seizures PProphylaxisrophylaxis  Phenobarbital no longer used routinelyPhenobarbital no longer used routinely  Antipyretics not effective in preventingAntipyretics not effective in preventing recurrencerecurrence  Rectal diazepam on stand-by forRectal diazepam on stand-by for repeat offendersrepeat offenders
    34. 34. Neonatal SeizuresNeonatal Seizures  Often harder toOften harder to differentiatedifferentiate  Jittery baby vs.Jittery baby vs. seizureseizure  Over 2/3 will haveOver 2/3 will have significantsignificant underlyingunderlying pathologypathology  May look wellMay look well
    35. 35. Neonatal SeizuresNeonatal Seizures CausesCauses – 50 - 60% secondary to hypoxic-ischemic50 - 60% secondary to hypoxic-ischemic insultinsult – 15% secondary to intracranial, subdural15% secondary to intracranial, subdural or subarachnoid bleedor subarachnoid bleed – 10% due to inborn errors of metabolism,10% due to inborn errors of metabolism, infection, metabolic disease or toxinsinfection, metabolic disease or toxins – Pyridoxine deficiencyPyridoxine deficiency – Benign familial neonatal convulsionsBenign familial neonatal convulsions – Benign idiopathic neonatal convulsionsBenign idiopathic neonatal convulsions
    36. 36. Neonatal SeizuresNeonatal Seizures TypesTypes  SubtleSubtle  TonicTonic  ClonicClonic  MyoclonicMyoclonic
    37. 37. Neonatal SeizuresNeonatal Seizures EvaluationEvaluation  Detailed birth historyDetailed birth history  ImagingImaging – All should be imaged (US, CT, or MRI)All should be imaged (US, CT, or MRI)  LabsLabs – Electrolytes, glucose, Ca, Mg, phosElectrolytes, glucose, Ca, Mg, phos – Toxicology screenToxicology screen – UA with micro and cultureUA with micro and culture – CBC and Blood cultureCBC and Blood culture – CSF studiesCSF studies  ExtrasExtras – Consider blood for amino acids, lactate, ammonia,Consider blood for amino acids, lactate, ammonia, pyruvate and urine for organic acidspyruvate and urine for organic acids
    38. 38. Neonatal SeizuresNeonatal Seizures TreatmentTreatment  ABC’sABC’s  Correct electrolyte abnormalitiesCorrect electrolyte abnormalities  AntibioticsAntibiotics  BenzodiazepinesBenzodiazepines  Phenobarbital before phenytoinPhenobarbital before phenytoin  Consider pyridoxineConsider pyridoxine  Consider acyclovirConsider acyclovir  ADMITADMIT
    39. 39. Questions?Questions?
    40. 40. ReferencesReferences  Friedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N AmFriedman MJ and Sharieff GQ. Seizures in Children. Pediatr Clin N Am 2006;53:257-277.2006;53:257-277.  Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a firstHirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Neurology 2000;55:616-623.nonfebrile seizure in children. Neurology 2000;55:616-623.  Eisner RF, Turnbull TL, Howes DS, Gold IW. Efficacy of a ‘Standard’ SeizureEisner RF, Turnbull TL, Howes DS, Gold IW. Efficacy of a ‘Standard’ Seizure Workup in the Emergency Department. Ann Emerg Med 1986; 15:69-75.Workup in the Emergency Department. Ann Emerg Med 1986; 15:69-75.  Turnbull TL, Vanden Hoek TL, Howes DS, Eisner RF. Utility of laboratoryTurnbull TL, Vanden Hoek TL, Howes DS, Eisner RF. Utility of laboratory studies in th emergency departemnt patient with new onset seizure. Annstudies in th emergency departemnt patient with new onset seizure. Ann Emerg Med 1990;19:373-377.Emerg Med 1990;19:373-377.  Nypaver mm, Reynolds SL, Tanz RR, Davis T. Emergency departmentNypaver mm, Reynolds SL, Tanz RR, Davis T. Emergency department laboratory evaluation of children with seizures: dogma or dilemma? Pediatrlaboratory evaluation of children with seizures: dogma or dilemma? Pediatr Emerg care 1992;8:13-16.Emerg care 1992;8:13-16.  Farrar HC, Chande VT, FitzpatrickDF, ShemmaSJ. Hypontaremia as theFarrar HC, Chande VT, FitzpatrickDF, ShemmaSJ. Hypontaremia as the cause of seizures in infants: a retrospective analysis of incidence, severity,cause of seizures in infants: a retrospective analysis of incidence, severity, and clinical predictors. Ann Emerg Med 1995;26:42-48.and clinical predictors. Ann Emerg Med 1995;26:42-48.  Rider LG, Thapa PB, Del Beccaro MA, et al. Cerebrospinal fluid analysisinRider LG, Thapa PB, Del Beccaro MA, et al. Cerebrospinal fluid analysisin children with seizures. Pediatr Emerg Care 1995;11:226-229.children with seizures. Pediatr Emerg Care 1995;11:226-229.  Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergentSharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatricsneuroimaging in children with new-onset afebrile seizures. Pediatrics 2003;111:1-6.2003;111:1-6.  Hirtz D, Birg A, Bettis Det al. Practice parameter: treatmentof the child with aHirtz D, Birg A, Bettis Det al. Practice parameter: treatmentof the child with a first unprovoked Seizure, Neurology 2003;60:166-75.first unprovoked Seizure, Neurology 2003;60:166-75.
    41. 41. ReferencesReferences  Warden CR, Zibulewsky J, Mace S, et al. Evaluation and management ofWarden CR, Zibulewsky J, Mace S, et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings.febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med 2003;41:215-222.Ann Emerg Med 2003;41:215-222.  Knudsen FU. Recurrence risk after first febrile seizure and effect of short termKnudsen FU. Recurrence risk after first febrile seizure and effect of short term diazepam prophylaxis. Arch Dis Child 1985;60:1045-1049.diazepam prophylaxis. Arch Dis Child 1985;60:1045-1049.  Berg AT, Shinnar S, Hauser WA, et al. Predictors of recurrent febrile seizures;Berg AT, Shinnar S, Hauser WA, et al. Predictors of recurrent febrile seizures; a metaanalytic review. J Pediatr 1990;116:329-327.a metaanalytic review. J Pediatr 1990;116:329-327.  Offringa M, Bossuyt PM, LubsenJ, et al. Risk factors for seizure recurrence inOffringa M, Bossuyt PM, LubsenJ, et al. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data fromchildren with febrile seizures: a pooled analysis of individual patient data from five studies. J Pediatr 1994;124:574-584.five studies. J Pediatr 1994;124:574-584.  Green SM, Rothrock SG, Clem KJ, et al. Can seizures be the soleGreen SM, Rothrock SG, Clem KJ, et al. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics 1993;92:527-534.manifestation of meningitis in febrile children? Pediatrics 1993;92:527-534.  Al-Eissa YA. Lumbar puncture in the clinical evaluation of children withAl-Eissa YA. Lumbar puncture in the clinical evaluation of children with seizures ssociated with fever. Pediatr Emerg Care 1995;11:347-350.seizures ssociated with fever. Pediatr Emerg Care 1995;11:347-350.  Lorber J, Sunderlind R. Lumbar puncture in children with convulsionsLorber J, Sunderlind R. Lumbar puncture in children with convulsions associated with fever. Lancet 1980;1:785-786.associated with fever. Lancet 1980;1:785-786.  Joffe A, McCormick M, DeAngelis C. Which children with febrile eizures needJoffe A, McCormick M, DeAngelis C. Which children with febrile eizures need lumbar puncture? A decision analysis approach. Am J Dis Childlumbar puncture? A decision analysis approach. Am J Dis Child 1983;137:1153-1156.1983;137:1153-1156.

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