Pediatric Seizure and SE Patient ED Care: Challenging Cases Edward P. Sloan, MD, MPH, FACEP 1

Pediatric Seizure and SE Pediatric Seizure and SE Patient ED Care:Patient ED Care:

Challenging CasesChallenging Cases

Edward P. Sloan, MD, MPH, FACEP1

Edward P. Sloan, MD, MPHEdward P. Sloan, MD, MPH

ProfessorProfessor

Dept of Emergency Medicine University Dept of Emergency Medicine University of Illinois College of Medicineof Illinois College of Medicine

Chicago, ILChicago, IL

Edward P. Sloan, MD, MPH, FACEP2

Attending Physician Attending Physician Emergency MedicineEmergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection Hospital

Chicago, IL

Edward P. Sloan, MD, MPH, FACEP3

Edward P. Sloan, MD, MPH, FACEP4

Housekeeping IssuesHousekeeping Issues

• Disclosures

• Meeting support from UCB Pharma– Thank you Dave Riccio

– IV levetiracetam, a second generation AED

– May soon be an IV parenteral option in the ED

• Please fill out a CME form with your email

• Please give feedback to improve our work

Edward P. Sloan, MD, MPH, FACEP5

OverviewOverview

Acute Pediatric SeizuresAcute Pediatric Seizures• Common ED problem

• Seizures: 6% of EMS encounters

• Pediatric seizures: 1% of all ED visits

• Pediatric febrile: 1 in 125 visits (0.8%)

• Pediatric afebrile: 1 in 500 visits (0.2%)

Edward P. Sloan, MD, MPH, FACEP6

ObjectivesObjectives

Management IssuesManagement Issues

• Learn likely sz etiologies

• Seizure Rx without IV access

• Review seizure termination Rx

• Explore IV Rx for SE prevention

• Review EEG in E.D. SE

• Discuss clinical impact

Edward P. Sloan, MD, MPH, FACEP7

Case PresentationsCase Presentations

ED Pediatric Seizure CasesED Pediatric Seizure Cases• Seizing infant, no IV access

• Pediatric status epilepticus

• Adolescent sz pt with seizures

• College student with new onset sz

• New onset SE in an adolescent

• Discussion

Edward P. Sloan, MD, MPH, FACEP8

Case #1:Case #1: Seizing infant, no IV accessSeizing infant, no IV access

• What therapies can be given?

• By what route?

• With what effect?

Edward P. Sloan, MD, MPH, FACEP9

Case #1Case #1

HxHx• 9 month old

• Febrile illness at home

• Seizing for paramedics

• Arrives in arms of CFD

• No IV access in field

Edward P. Sloan, MD, MPH, FACEP10

Case #1Case #1

PxPx• Hyperpyrexia, abn vital signs

• Actively seizing, generalized

• Tonic-clonic motor activity

• Cardiopulm exam OK

• No IV access available

Edward P. Sloan, MD, MPH, FACEP11

Case #1Case #1

DxDx• What are the diagnoses in this

child?

Edward P. Sloan, MD, MPH, FACEP12

Case #1Case #1

DxDx• Generalized convulsive status

epilepticus (GCSE)

• Complex febrile seizure

Edward P. Sloan, MD, MPH, FACEP13

Case #1Case #1

Rx: Non-IV OptionsRx: Non-IV OptionsWhat treatment would you provide

for this patient?

A. PR diazepam or rectal gel

B. Buccal midazolam

C. IM fosphenytoin

D. IM midazolam

E. IM phenobarbital

Edward P. Sloan, MD, MPH, FACEP14

Case #1Case #1

Rx: Non-IV OptionsRx: Non-IV Options• IM midazolam

• Buccal midazolam

• IM fosphenytoin

• PR diazepam

• PR diazepam rectal gel

• IM phenobarbital less good

Edward P. Sloan, MD, MPH, FACEP15

Case #2: Case #2:

Pediatric SEPediatric SE

• How do we diagnose ped SE?

• What is the optimal Rx protocol?

• Why?

Edward P. Sloan, MD, MPH, FACEP16

Case #2Case #2

HxHx• 7 year old male

• Seizure-like activity?

• Patient with staring spells

• Some headache and shaking movement, esp of hands

• Frontal headache, vomiting

Edward P. Sloan, MD, MPH, FACEP17

Case #2Case #2

Hx (con’t)Hx (con’t)

• Seen at 2130, 2230 sign-out

• AMS, r/o seizure disorder

• “Once all of the labs are back, he should be OK to go home…”

Edward P. Sloan, MD, MPH, FACEP18

Case #2Case #2

PxPx

• 98.7 98/60 72 20

• Well hydrated

• CV, lung exams normal

• Neuro exam intact

Edward P. Sloan, MD, MPH, FACEP19

Case #2Case #2

Px (con’t)Px (con’t)

• 0220 “episode”

• Tachycardia, assoc with AMS

• Confused, staring off into space

• Resolved without any Rx

• Three more episodes over 40’

• Diaphoresis, urinary incontinence

Edward P. Sloan, MD, MPH, FACEP20

Case #2Case #2

DxDxWhat is the likely diagnosis in this

pediatric patient?

A. Absence status epilepticus

B. Complex partial status epilepticus (CPSE) with autonomic signs

C. Generalized non-convulsive seizure with autonomic signs

D. Generalized convulsive SE

Edward P. Sloan, MD, MPH, FACEP21

Case #2Case #2

DxDx• Repetitive episodes with AMS

• Associated autonomic signs

• Rule out generalized nonconvulsive status epilepticus – Complex partial status epilepticus

– Absence status epilepticus

Edward P. Sloan, MD, MPH, FACEP22

Case #2Case #2

RxRx

How would you initially treat this pediatric seizure patient?

A. IV diazepam

B. IV lorazepam

C. IV phenobarbital

D. IV valproate

E. Rectal diazepam

Edward P. Sloan, MD, MPH, FACEP23

Case #2Case #2

RxRx

Would you load this patient with another antiepileptic drug prior to transfer to the children’s hospital?

A. Yes

B. No

Edward P. Sloan, MD, MPH, FACEP24

Case #2Case #2

RxRx

If you were to load this patient with an AED, what agent would you use?

A. IV phenytoinB. IV fosphenytoinC. IV phenobarbitalD. IV valproateE. Other

Edward P. Sloan, MD, MPH, FACEP25

Case #2Case #2

RxRx

• IV lorazepam

• IV valproate

• Transfer to Children’s for ICU observation

Edward P. Sloan, MD, MPH, FACEP26

Case #3: Case #3:

Adolescent Sz Pt with Adolescent Sz Pt with SeizuresSeizures

• How to manage seizing children on PO valproate?

• Does a level need to be checked prior to ED loading?

• When and how to rapidly restore a therapeutic level?

Edward P. Sloan, MD, MPH, FACEP27

Case #3Case #3

HxHx• 12 yo F• Hx autism• Hx complex partial seizures• Hx secondary generalized tonic-

clonic seizures• Pt taking Depakote sprinkles BID• Presents to ED, has 2nd seizure

Edward P. Sloan, MD, MPH, FACEP28

Case #3Case #3

PxPx• VS OK prior to seizure

• Chest: Clear

• CV: Reg without

• Neuro: Non-focal

• Generalized tonic-clonic seizure

Edward P. Sloan, MD, MPH, FACEP29

Case #3Case #3

DxDx• Generalized seizures

• Hx complex partial seizures

• Sub-therapeutic valproate level vs. break-thru seizure

Edward P. Sloan, MD, MPH, FACEP30

Case #3Case #3

RxRxAfter an initial dose of a

benzodiazepine is given, would you obtain a valproate level prior to giving IV valproate?

A. Yes

B. No

Edward P. Sloan, MD, MPH, FACEP31

Case #3Case #3

RxRxTo achieve a high therapeutic level

of 125 ucg/ml, if the measured level is 25 ucg/ml, how much IV valproate should be administered in mg/kg ?

A. 100 mg/kgB. 50 mg/kgC. 20 mg/kgD. 5 mg/kg

Edward P. Sloan, MD, MPH, FACEP32

Case #3Case #3

RxRx• IV lorazepam, avoid status epilepticus

• Determine valproate level

• For every mg/kg loaded, the level goes up 5 mcg/ml

• To increase the level by 100 mcg/ml, give 20 mg/kg. For a 50 kg child, give 1000 mg of IV valproate

Edward P. Sloan, MD, MPH, FACEP33

Case #4: Case #4:

College Student, New Onset SzCollege Student, New Onset Sz

• What is the likely etiology?

• What are the long-term implications?

• How to manage once the seizure has stopped?

Edward P. Sloan, MD, MPH, FACEP34

Case #4Case #4

HxHx• 21 year old college student

• No known neuro history

• Final exams, sleepless

• Great party after the last exam

• Pt with single generalized seizure in am, upon awakening

Edward P. Sloan, MD, MPH, FACEP35

Case #4Case #4

PxPx

• Vitals OK

• Neuro: slightly post-ictal

• Exam otherwise normal

• Patient has a 2nd seizure in the ED

Edward P. Sloan, MD, MPH, FACEP36

Case #4Case #4

DxDxWhat is the likley diagnosis in this

young adult?

A. Complex partial seizures with secondary generalization

B. Juvenile myoclonic epilepsy

C. Generalized tonic-clonic seizure

D. Absence seizure

Edward P. Sloan, MD, MPH, FACEP37

Case #4Case #4

DxDx• Juvenile myoclonic epilepsy

• Related to sleep deprivation, alcohol consumption, occurs upon awakening

• May have a history of myoclonic jerks

• Responds long-term best to valproate

Edward P. Sloan, MD, MPH, FACEP38

Case #4Case #4

RxRx• Benzodiazepines to Rx the acute sz

• Ongoing protection an issue• Phenytoin may not be optimal• Valproate may be preferred

• Avoid status epilepticus

Edward P. Sloan, MD, MPH, FACEP39

Case #5:Case #5: New Onset AMS/SpellsNew Onset AMS/Spells

• What is the AMS?

• Is it a seizure?

• How should we Rx new onset seizure patients?

• What role does the ED EEG play in sz and SE?

Edward P. Sloan, MD, MPH, FACEP40

Case #5Case #5

HxHx• 13 year old female

• HA, frontal, cw prior migraines

• HA relieved with ibuprofen

• AMS this AM, with ? motor activity

• Restless at home, thrashing on bed

• No other systemic sx

Edward P. Sloan, MD, MPH, FACEP41

Case #5Case #5

PxPx• Vitals OK, afebrile

• Alert, O x 3, NAD

• Head/Neck OK

• Chest/cor/abd OK

• Neuro: No focal deficit. MS OK

Edward P. Sloan, MD, MPH, FACEP42

Case #5Case #5

Question # 1Question # 1

• What diagnostic tests are indicated at this point?

Edward P. Sloan, MD, MPH, FACEP43

Case #5Case #5

Question # 2Question # 2

Did this patient have a seizure? A. YesB. No

Edward P. Sloan, MD, MPH, FACEP44

Case #5Case #5

Question # 3Question # 3

Does the patient require admission for observation for possible new onset seizures?

A. YesB. No

Edward P. Sloan, MD, MPH, FACEP45

Case #5Case #5

Clinical CourseClinical Course

• Labs, tox screen neg

• CT negative

• Neuro consult: EEG and then D/C

• Dx: Seizure, migraine HA

• While EEG applied, pt with AMS

• Agitation, thrashing on cart

Edward P. Sloan, MD, MPH, FACEP46

Case #5Case #5

Question # 4Question # 4

• Is this repeat spell a seizure? • What type?

Edward P. Sloan, MD, MPH, FACEP47

Case #5Case #5

Question # 5Question # 5

• Does this AMS, motor activity require Rx?

• What Rx?

Edward P. Sloan, MD, MPH, FACEP48

Case #5Case #5

Question # 6Question # 6

• Does the patient require admission for observation for possible new onset seizures?

Edward P. Sloan, MD, MPH, FACEP49

Case #5Case #5

Clinical Course (con’t)Clinical Course (con’t)

• During EEG, pt with R face focal sz• Leftward gaze noted• Seizure then generalizes• Meds are given• Seizure is terminated

Edward P. Sloan, MD, MPH, FACEP50

Case #5Case #5

Question # 7Question # 7

• What med is to be used for seizure control / SE termination?

Edward P. Sloan, MD, MPH, FACEP51

Case #5Case #5

Question # 8Question # 8

• What med is to be used once SE is terminated?

• Why?

Edward P. Sloan, MD, MPH, FACEP52

Case #5Case #5

Question # 9Question # 9

• How should the meds be given?

• Why?

Edward P. Sloan, MD, MPH, FACEP53

Case #5Case #5

Clinical Course (con’t)Clinical Course (con’t)

• SE terminated with Rx

• Pt stabilized

• ALS transfer to Children’s with team

• Pt with resolving AMS at time of D/C

Edward P. Sloan, MD, MPH, FACEP54

Case #5Case #5

RxRx

• Lorazepam to Rx the acute sz

• IV phenytoin, fosphenytoin, valproate, phenobarbital are AED load options

• PRN meds during transfer

Edward P. Sloan, MD, MPH, FACEP55

Case #5Case #5

DxDxWhat is the diagnosis in this

young patient?

A. Absence seizure

B. Complex partial seizures with secondary generalized seizure

C. Focal motor seizure

D. Complex migraine headache

Edward P. Sloan, MD, MPH, FACEP56

Case #5Case #5

DxDx

• New onset seizure/SE

• Complex partial seizure with secondary generalized seizure

• Hx migraine headaches

Edward P. Sloan, MD, MPH, FACEP57

Case #5Case #5

DxDx

Do you believe you could diagnose a seizure on an EEG?

A. Yes

B. No

Edward P. Sloan, MD, MPH, FACEP58

Edward P. Sloan, MD, MPH, FACEP59

Edward P. Sloan, MD, MPH, FACEP60

Edward P. Sloan, MD, MPH, FACEP61

Edward P. Sloan, MD, MPH, FACEP62

Edward P. Sloan, MD, MPH, FACEP63

Edward P. Sloan, MD, MPH, FACEP64

Edward P. Sloan, MD, MPH, FACEP65

ConclusionsConclusions

Key Learning PointsKey Learning Points• Acute, repetitive spells = sz

• Multiple meds and routes possible

• Opportunity to optimize Rx

• Acute seizure control: IV benzos

• 2nd line Rx may differ based on Dx

• Ongoing needs may influence 2nd Rx

• EEG may be of use in ED seizures

Edward P. Sloan, MD, MPH, FACEP66

RecommendationsRecommendations

Management ImplicationsManagement Implications• Educate about sz etiologies

• Make multiple drugs available

• Alternate routes should be used

• A protocol should exist

• Utilize EEG when necessary

• Be aware of optimal Rx at disposition

Edward P. Sloan, MD, MPH, FACEP67

CME QuestionCME Question

Have you learned something new about pediatric seizures today such that you can change and improve your clinical practice?

A. Yes

B. No

Edward P. Sloan, MD, MPH, FACEP68

CME Follow-upCME Follow-up

CME providers require follow-up to assess if your learning has indeed improved your clinical practice. Can we ask you this question via email again in the future?

A. YesB. No

Questions??Questions??

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04/10/23 23:56 Edward P. Sloan, MD, MPH, FACEP

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Edward P. Sloan, MD, MPH, FACEPEdward P. Sloan, MD, MPH, FACEPedsloan@uic.edu

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