MARMOR Ped Seizures - ucsfcme.com

Andi Marmor, MD, MSEdAssociate Professor, PediatricsUniversity of California, San Francisco

Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments

Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments

Tesla is a previously healthy 16 mo girlBIB ambulance after she “had a seizure” Fell to the ground while playing and became stiff and non‐responsive, eyes rolled back, for 30 seconds – 911 called

No apnea or focal movements noted Sleepy but responsive in the ambulance, T = 37.9

Febrile to 39.0, VS otherwise WNL Neuro: Moving all extremities, fussy but consolable by father

Initially sleepy but becoming more and more alert as you observe her

No source for fever is apparent on history/PE

A. Obtain blood, urine and CSF culturesB. Admit for neurologic evaluationC. Obtain a head CT or MRID. Obtain a stat EEGE. Discharge when at neurologic baseline

Etiology: NOT fever!

Cytokines!

“Simple” Febrile Seizure

Short, generalized, isolated

Generally considered benign

“Complex” Febrile Seizure

Longer OR focal OR recurrent

May be more concerning?

HHV-6: Roseola

NO: Rates of SBI in SFS similar to age‐matched febrile children

Meningitis?

No cases of meningitis in the absence of focal signs/symptoms in series’ of SFS/CFS

However, meningitis can present with fever and seizure….

Failure to return to normal MS/Focal neuro exam

Febrile convulsive statusKimia, 2010; Fletcher 2013

Your patient comes back within 24 hours with another short, generalized seizure

Now what would you do? Even children with CFS are at very low risk for SBI/meningitis

LP can be done in select children with concerning features

Febrile status, focal/abnormal neuro exam, recent antibiotics

Kimia, 2010; Fletcher 2013

EEG: Not useful in predicting recurrence or epilepsy, even in complex febrile seizures

Anticonvulsants/antipyretics : do not alter course

Confirm child has no neurologic abnormality Identify and treat source for fever, by age Further workup based on H and P

LP for convulsive status, abnormal neuro exam

Consider LP for

Recent antibiotics, several days of fever before sz

Consider referral to neuro for

Focal seizure or recurrent complex seizure

DC when back at neurologic baseline Educate on recurrence: 10‐50%

Younger age, family history, complex seizure, lower temperature

Treat fevers appropriately for comfort only

Leaf is a 2 yo boy BIB ambulance after a generalized, tonic clonic seizure

Given rectal diazepam seizure has ceased

No prior seizures, developmentally normal

Deny trauma, recent illness, travel, change in diet.

He is afebrile, sleepy but arousable

Pushes you away purposefully and symmetrically, and knows his name and age

A. Head CT B. Head MRIC. Complete H and PD. CBC and electrolytesE. Lumbar puncture

Yield of imaging in children with a first‐time afebrile seizure is very low

8% in one study (Sharma, 2003), with < 1% requiring immediate management

Findings requiring intervention can be predicted by

Predisposing factors (trauma, bleeding disorder)

Age < 6 months

Persistent neurologic abnormality

Neuroimaging, screening labs and/or lumbar puncture should not be routinely performed

Consider imaging in the ED (CT or MRI) if

History concerning for IC abnormality

Persistent neurologic abnormality

< 6 mo of age

Schedule pediatric/neurology follow up

May include EEG, MRI if indicated (eg: focal seizure, < 3 years of age)

Hirtz, 2000

Your resident calls you back in because Leaf has started to seize again

The seizure is generalized, and he is breathing on his own

VS: HR 150, RR 30, BP 110/75 You are concerned that Leaf is now in status epilepticus

The RN mentions that the IV is not flushing

A. IV lorazepamB. IM lorazepamC. IM midazolamD. Rectal diazepamE. Buccal midazolam

If IV access: IV lorazepam (0.1mg/kg) quickest onset/ preferred treatment for all age groups

Non‐IV options:

Buccal midazolam (0.5mg/kg): fastest option if time for IV access included

Intranasal midazolam/lorazepam: requires atomizer

Both superior to rectal/IV diazepam in RCT’s

Using highest concentration solution (5mg/ml)

1ml syringe without needle

Administer between cheek and teeth Half on each side

• ½ in each nostril• Great for fentanyl for

painful procedures as well!• Must use atomizer

If you have an IV: IV lorazepam If you don’t have an IV: buccal midazolam Other options: Intranasal lorazepam or midazolam

After 2 doses of benzo, start fosphenytoin(unless < 1 mo)

IV infusion or IM

Febrile Seizures: No additional studies needed for SFS or CFS if neuroexam improving at 30 min and normal at 1 hour

Consider LP if: < 12 moAND previous antibiotic treatment, seizure late in illness

Afebrile Seizures: Imaging rarely indicated, if normal exam and no predisposing factors

Treat pediatric status epilepticus with IV lorazepam or buccal midazolam x2

Then fosphenytoin

Andrea Marmor, MD UCSF High Risk Emergency Medicine May, 2014

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Pediatric Seizures Andi Marmor, MD ([email protected])

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FEBRILE SEIZURES ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What evaluation is indicated after a febrile seizure? Background

Definition: A seizure occurring in an otherwise well child 6 mo to 5 years of age without a seizure disorder or underlying neurologic disease, who is febrile or becomes febrile within 30 min of the seizure

Febrile seizures are generally considered a benign condition of childhood, and do not carry any significant risk of neurologic sequelae

Simple febrile seizures (SFS) are short (<15min), generalized, non‐recurring in 24 hours

Complex febrile seizures (CFS) may be prolonged, focal or recurring

The most controversial question that arises for children with a febrile seizure is whether LP is indicated Epidemiology:

Febrile seizures account for about 80% of first time pediatric seizures o Occur in 2‐5% of all children, with no geographic, racial or ethnic differences in incidence o Family history in 25‐40% of cases

About 80% are “simple febrile seizures” o Complex febrile seizures (CFS) cause a higher degree of concern, and are associated with higher rates of

status epilepticus, recurrence and epilepsy

Viral infections are the most common associated finding (especially HHV‐6); also recent vaccination with DTaP Etiology:

Mounting evidence suggests that the etiology for febrile seizures is inflammatory cytokine elevations, rather than elevated body temperature (Straussberg, 2001)

HHV‐6 and HHV‐7 infection seems to be a major viral cause of febrile seizures o 13‐36% of kids with HHV‐6 have febrile seizures, and up to 7% of those with HHV‐7 (Oluwabusi, 2012) o Implicated in up to 1/3 of first‐time febrile seizures (Oluwabusi, 2012)

Of note, fever may not be detectable at the time of seizure, but may present up to 30 minutes after the seizure

Febrile seizures typically occur at the onset of a febrile illness o Seizures occurring in children who have been febrile for several days, or those who have been pre‐treated

with antibiotics, should be managed more conservatively

SFS accompanying a febrile illness does not indicate more severe infection: o Rates of serious bacterial infection (particularly acute bacterial meningitis ‐ ABM) in infants/children with

SFS are no higher than febrile children without seizures. o Several recent studies have established that even CFS is rarely the sole presenting sign of meningitis

Prognosis:

No increased risk of mortality, hemiplegia or mental retardation in children with SFS

Risk of epilepsy slightly higher with SFS than in general population o Risk of epilepsy higher with complex features: recurrent or focal seizures, or febrile status epilepticus

Recurrence of febrile seizures occurs in about 10‐50%, depending on risk factors o Age < 12 mo, +family hx, lower temperature or complex seizure all increase risk of recurrence

Evaluation:

Simple febrile seizure: Most guidelines recommend no testing or imaging in addition to that indicated for evaluation of the fever itself

o AAP Practice Parameter 2011: Recommends against routine blood, CSF, EEG, or imaging studies Targeted evaluation only, as determined by age‐appropriate guidelines for febrile illnesses LP is “optional” in children 6‐12 mo: consider if unimmunized, or pre‐treated with abx

o Recent studies add support to evidence that rates of SBI (including meningitis) in children with SFS are similar to those among age‐matched febrile children without seizures (Trainor, Shah, Green).

o There have been no documented cases of bacterial meningitis presenting with SFS alone (Hampers 2011, Oluwabusi 2012, Hom 2011)

o Routine labs/EEG (electrolytes, glucose, CBC) are of no benefit in the evaluation of the child with 1st SFS.


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o Multiple studies have established that treatment with anti‐convulsants or antipyretics does not alter recurrence or prognosis (Strengell, 2009)

Complex febrile seizure: Evaluation after CFS is less well‐established – concern is higher for a serious bacterial infection, but multiple studies show rates of SBI remain low in otherwise well‐appearing children with CFS

o Certain features of CFS (such as focality, status epilepticus) may carry more risk than others (Kimia, 2010) o While up to 25% of children with acute bacterial meningitis (ABM) present with seizures, ABM is extremely

rare in children presenting ONLY with CFS (Hampers, 2011) Kimia (2010): retro review of 526 children with CFS, 65% had LP

14 pts had CSF pleocytosis, 2 pts had ABM (both with S. pneumo: 0.9% of those with LP)

Both pts with ABM were ill‐appearing and had focal neuro signs before/after seizure Fletcher (2013): retro review of 193 pts with first CFS, 70% had LP

Those with focality, status epilepticus or needing intubation more likely to get LP

14 pts had pleocytosis, no pts had confirmed ABM (1 was treated empirically) o Routine EEG has no utility in predicting recurrence development of epilepsy in children with CFS

Recommendations

1. In any child 6 mo ‐5 years of age presenting with a febrile seizure (simple or complex): Confirm that the child has no known brain abnormality or previous neurologic insult Verify that neurologic exam steadily improves after brief post‐ictal period, and is at baseline within 1 hour

of seizure Identify and treat the source for their fever, in an age‐appropriate manner

If no source is found, proceed to evaluate for fever without a source (FWS) as indicated, taking into account age, appearance and immunization status (may include testing for UTI)

2. Simple Febrile Seizure: No additional studies are recommended after a simple febrile seizure in a well‐appearing child with a

normal neuro exam 3. Complex Febrile Seizure:

If child is previously well and returns to neurologic baseline after seizure, no additional studies are needed Additional targeted evaluation recommended if

Febrile convulsive status epilepticus Intubation Failure to return to baseline after seizure

Consider evaluation for metabolic, infectious or neurologic causes more strongly if: Infant <6 mo of age Focal characteristics of seizure

4. Additional studies for special situations: Lumbar puncture

Recommended in child with meningeal signs/symptoms, or who fails to return to neurologic baseline Consider in the child who has received recent abx, or who has been febrile for several days prior to seizure Neuroimaging before lumbar puncture only recommended if focal neurologic findings are present If LP is performed, CSF pleocytosis (WBC > 20x106) should not be attributed to seizure alone, and should

prompt further evaluation and treatment for bacterial or viral meningitis Electrolytes, glucose, CBC

Only as specifically indicated by the child’s history or PE EEG

Usually not recommended in ED for febrile seizures May be performed as an outpatient for complex or focal seizures

Neuroimaging Consider for focal seizure with persistent focal neuro exam, concern for child abuse, history of trauma

5. Discharge and follow‐up: Routine use of antipyretics/anticonvulsants is NOT recommended for prevention of recurrence or epilepsy Education and reassurance of parents/guardians and arrange primary care follow up Further neurologic workup (usually outpatient) may be indicated for children with complex or focal

seizures, or with recurrent febrile seizures arousing parental concern


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Update on Pediatric MeningitisTrends in Incidence and Microbiology

Overall, meningitis has declined significantly in the last 10 years, especially in the 2‐23 month age group

Thigpen (2011) reported trends in incidence and microbiology of meningitis from 1998 ‐2007. o Incidences declined significantly for all age groups except for < 2 mo (increase by 10%, 95% CI = 1‐20)

Decrease in incidence primarily due to S. pneumo decreases Incidence remains highest for patients under 2 mo of age

o The decline was greatest in the 2‐23 mo age group, resulting in an increase in median age (from 30 to 40) o Ethnic disparities remain, with incidence highest in black patients of any age o No change in case fatality rate overall (7%, highest for S pneumo) o All pathogens decreased significantly overall, except for GBS

S. pneumo decreased by 26% , N mening by 58%, H flu by 35% PCV‐7 serotypes decreased 92% overall, but ABM from non‐PCV7 serotypes increased by 61%

Risk of meningitis in different age groups

1. Neonates:

Despite decreases in SBI in neonates, rates of meningitis in infants < 2 mo have not declined (Thigpen, 2011) 2. Infants 1‐3 mo of age

Overall, meningitis is extremely rare in this age group, especially in infants meeting low‐risk criteria (well‐appearing, with negative UA, and normal inflammatory markers)

3. Infants 3 mo to 2 years

In the post‐PCV era, occult meningitis is extremely rare in this age group and LP is not recommended if well‐appearing

Management: Steroids:

A large body of evidence now exists to support the use of steroids prior to antibiotics as an adjunct to the treatment of bacterial meningitis in children.

o Overall, corticosteroids are associated with lower mortality, hearing loss and long‐term neurologic sequelae in both children and adults, for both H. influenza and pneumococcal meningitis

Timing: No benefits have been shown when corticosteroids are administered after antibiotics

Duration of therapy: Most trials studied 4 days of therapy at doses of 0.6‐1 mg/kg/day. No randomized trials have directly compared 2‐day to 4‐day therapy.

Recommendations:

1. Perform Lumbar puncture and start empiric antibiotics in Any febrile infant/child who is toxic appearing or has focal neurologic signs, of any age

2. Strongly consider LP if giving empiric antibiotics for Suspected SBI in infants < 3 mo (eg: for elevated inflammatory markers) or A young, febrile infant in whom clinical assessment is limited (eg: pre‐treated with antibiotics)

3. Steroids Recommended in infants/children >6 weeks of age: as an adjunct to antibiotics in suspected or proven S.

pneumo or H. influenza meningitis Initiate steroid therapy as soon as possible in infants/children >6 weeks of age with suspected or proven S.

pneumo or H. influenza meningitis o Only shown to be effective when given prior to antibiotics

Whenever possible, obtain blood and CSF cultures prior to initiating antibiotics, but do not delay treatment in cases of suspected meningitis

Dosing: dexamethasone 0.15mg/kg every 6 hours Continue steroid therapy for 4 days, in patients with proven or suspected S. pneumo or H. influenza

Discontinue steroids in patients with a completely negative CSF cell count


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▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ NON‐FEBRILE SEIZURES

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: When is neuroimaging needed for a first‐time non‐febrile seizure? Background

While seizures represent ~2% of pediatric ER visits, only ~20% of these are non‐febrile seizures

Guidelines for imaging in adult patients are based on a high rate of abnormal imaging, with a high proportion of structural lesions requiring immediate therapy.

Evidence

A 2000 practice parameter by the American Academy of Neurology (Hirtz, 2000) concluded that there was insufficient evidence to support a recommendation to routinely perform a lumbar puncture, laboratory studies, or routine neuroimaging in a child >6 months of age after a first unprovoked, nonfebrile seizure.

More recent studies support this selective approach to imaging/diagnostic testing: o Maytal (2000): retrospective study of 63 kids with new‐onset seizures: those with clinically significant

findings on CT were all predicted by history/physical findings o Sharma, 2003 ‐ Retrospective review of 500 1st time afebrile seizures at Boston Children’s ‐ 8% had

clinically significant imaging abnormality (<1% required immediate mgmt). Risk fx for clinically significant abnormalities: 1) predisposing condition 2) focal seizure and < 33 mo

Studies show similar clinical variables predicting those at “high risk” for abnormal imaging: o Predisposing factors for IC abnormality (bleeding D/O, closed head inj, malignancy, HIV, sickle cell dz, etc) o Focal seizure in child <3 yrs (although findings not of immediate therapeutic significance) o Persistent neurologic abnormality (altered consciousness, focal deficits)

Children without these risk factors are very unlikely (1% or less) to have an imaging abnormality requiring ED intervention

Choice of imaging: CT vs MRI o CT has traditionally been used in ED setting for its rapid availability and lack of sedation needed. o MRI is a better study for subtle abnormalities, but unlikely to be of significance in the ED setting. o As MRI is becoming faster and more available, it may be a viable radiation‐free option for pediatric

neuroimaging in the ED Recommendations

1. Every child who has a first, afebrile, non‐provoked seizure should have a complete history and physical to ascertain any provoking events or conditions (trauma, toxins, illness, etc) or neurologic deficits

2. Emergent neuroimaging (CT scan) is not indicated in the ED if: > 6 months of age Normal neuro exam No risk factors/predisposing factors for treatable cause for seizure (eg: bleeding disorder, trauma) Reliable follow up

3. MRI may be used in place of CT if imaging is indicated in the ED and MRI is easily available 4. Screening blood work and/or lumbar puncture should be performed only if specific etiology suspected by H and P 5. Initiating treatment with anti‐epileptics after a first seizure is not recommended 6. Educate parents about the significance and implications of the seizure, and schedule follow up with the child’s

pediatrician or a neurologic consultation within a week. Outpatient workup may include: EEG – potentially helpful in classifying seizure, guiding therapy/prognosis MRI ‐ may be indicated especially in those < 3 with focal seizures.

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PEDIATRIC STATUS EPILEPTICUS ▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ Question: What are the best drugs for pediatric convulsive status epilepticus (SE)? Background

Delays in treatment of pediatric SE are common, and dosing errors (high or low) are widely reported (Abend, 2010)

Rapid treatment is important, as delay is associated with increased risk of prolonged status, medication failure, and worse outcomes (Abend, 2010, Sofou 2009)

In general, seizure control prior to 30 minutes is the goal


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Lack of IV access may slow the administration of preferred drugs Evidence:

IV lorazepam (0.1mg/kg, max 4mg) o The safest and most effective initial drug for acute pediatric seizures/SE in all age groups (Appleton, 2010)

Non‐IV options: o Buccal midazolam* (0.5mg/kg, max 10mg):

Superior to rectal diazepam (Appleton, 2010) with seizure control rate of 70% (Sofou 2009) *Most concentrated IV solution should be used: 5mg/ml recommended

o Intranasal* midazolam (0.2mg/kg) or IM midazolam (0.2 mg/kg): Faster than IV diazepam (Sofou, 2009; Silbergleit 2012)

o Intranasal* lorazepam (0.1mg/kg, max 4mg) Superior to IM paraldehyde in an RCT in Africa, longer acting than midazolam

*Intranasal administration requires a nasal atomizer

Fosphenytoin, if available, is superior to phenytoin in safety, and recommended as first‐line for established SE o Dosing in “phenytoin equivalents” = PE o Can be administered more quickly than phenytoin, and IM as well

Recommendations (see Figure 1 in appendix):

1. Initiate treatment promptly, and progress through treatment options quickly A protocol for pediatric status epilepticus may improve speed, consistency and efficacy of treatment

2. The preferred initial treatment for pediatric seizures is IV lorazepam, up to 2 doses If IV access is unavailable, alternatives in order of preference, include:

o Buccal midazolam (0.5mg/kg, max 10 mg) o IM midazolam (0.2mg/kg, max 10 mg) o Intranasal lorazepam (0.1mg/kg, max 4 mg) – consider if suspected ongoing sz focus (eg; CNS infection)

3. Established SE (fails to stop within 5 min of 2nd dose of benzodiazepine): Start infusion of fosphenytoin (preferred) or phenytoin Fosphenytoin (30 PE/kg) IV over 10 min (or IM); or phenytoin 25 mg/kg over 20 minutes For child < 1 mo, skip this step and use phenobarbital, 20 mg/kg IV over 10 minutes

4. Refractory SE (fails to respond to fosphenytoin infusion) Children < 2 years: IV phenobarbital (20 mg/kg IV over 10 min) Children > 2 years: IV valproate (20 mg/kg IV over 4 min)


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Figure 1: UCSF Treatment Guideline for Pediatric Convulsive Status Epilepticus By Kendall Nash and Andi Marmor – UCSF Pediatric Neurology and General Pediatrics

This guideline is a recommendation for clinical care and has not been prospectively validated

YES

0‐10 MINUTES: IMPENDING STATUS EPILEPTICUS*

Skip this step if pt received 2 doses of any benzodiazepine prior to ED

Preferred: Lorazepam: 0.1 mg/kg IV (max 4mg) o Repeat in 5 min if persistent seizure (MAX 2 doses, including pre‐ED doses)

If no IV access: midazolam 0.5mg/kg of IV solution given buccally or 0.2 mg/kg IM (max 10mg)

Brief, targeted H&P and selected labs (consider glucose, Na, Ca, CBC)

10‐20 MINUTES: ESTABLISHED STATUS EPILEPTICUS*

Fosphenytoin: 30 mg PE/kg IV or IO, run over 10 minutes, or IM (max 150 mg/min)

Consult neurology or pediatric neurology, if available

Delay neuroimaging until seizure controlled unless concern for emergent intracranial process *Order valproate/levetiracetam or phenobarbital: may take time to get from pharmacy

*Consider pyridoxine if INH suspected (1g/g ingested, max 5g initial dose)

Continue evaluation, as indicated by H & P (BMP, LFT’s, tox, AED levels)

Consider neurology consult

Admit to Pediatrics

If intubated/unconscious: to PICU for EEG monitoring

YES

NO

NO

YES

20‐30 MINUTES: REFRACTORY STATUS EPILEPTICUS**Call PICU to arrange for admission/transfer

45 MINUTES: COMA INDUCTION (IN PICU)

Midazolam 0.2 mg/kg IV bolus (max 10mg), start infusion at 0.1 mg/kg/hour o Repeat bolus and increase infusion rate by 0.1mg/kg/hr (max 2 mg/kg/hr) every 5 min until seizure cessation on EEG

If seizure persists, start pentobarbital (10mg/kg IV bolus, infusion at 1mg/kg/hr) and wean midazolam o Repeat bolus (5mg/kg) q 30 min and increase infusion by 1mg/kg/hr q hr until seizure cessation AND burst‐suppression on EEG

Continue coma meds X 24 hrs after last seizure, then wean (if recurrent seizures, restart and add topiramate 10mg/kg NG) o Wean: reduce midazolam gtt by 0.05mg/kg/hour q3h; reduce pentobarbital gtt by 1mg/kg/hr q6h

Child > 2 years

NO

Admit to PICU for EEG monitoring

CHILD ARRIVES IN ED SEIZING

Child 1 mo‐ 2 years

Seizure stopped?

Valproate 20 mg/kg IV over 4 min unless contraindicated* *If known or suspected inborn error or liver disease, use levetiracetam 30 mg/kg IV (max 3 g) over 6 min

Phenobarbital 20 mg/kg IV over 10 min

Prepare for intubation

If seizure persists: Repeat 20 mg/kg IV over 10 min X1

Seizure stopped after fosphenytoin load?

Seizure stopped within 5 min of 2nd dose of benzodiazepine?


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▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ REFERENCES

▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪▪ 1. Abend NS, et al. Medical treatment of pediatric status epilepticus. Semin Pediatr Neur 2010; 17: 169‐175 2. American Academy of Pediatrics, Subcommittee on Febrile Seizures Clinical Practice Guideline – Febrile Seizures:

Guideline for the Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure. Pediatrics 2011; 127:389 – 394

3. Appleton R, et al. Drug management for acute tonic‐clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev 2008; 16(3): CD001905

4. Arditi M, Mason EO, Bradley JS, et al. Three‐year multi‐center surveillance of pneumococcal meningitis in children: clinical characteristics and outcome related to penicillin susceptibility and dexamethasone use. Pediatrics 1998; 102: 1987‐97

5. Batra P, Gupta S, Gomber S, Saha A. Predictors of meningitis in children presenting with first febrile seizures. Pediatr Neurol 2011; 44: 35 – 39.

6. Boyle DA, Sturm JJ. Clinical factors associated with invasive testing and imaging in patients with complex febrile seizures. Pediatr Emerg Care 2013; 29(4): 430‐4

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8. Chen C‐Y, et al. New‐onset seizures in pediatric emergency. Pediatr Neonatal 2010; 51(2): 103‐111 9. Fletcher EM, Sharieff G. Necessity of lumbar puncture in patients presenting with new onset complex febrile

seizures. West J Emerg Med 2013; 14 (3): 206‐11 10. Freedman SB, Powell EC. Pediatric seizures and their management in the emergency department. Clin Ped Emerg

Med Sept 2003; 4(3): 195‐206 11. Freeman JM. Less testing is needed in the emergency room after a first afebrile seizure (letter). Pediatrics Jan 2003;

111(1): 194‐196 12. Gaillard WD, et al. Guidelines for imaging infants and children with recent‐onset epilepsy. Epilepsia 2009; 50(9):

2147‐2153 13. Green SM, Rothrock SG, Clem KJ. Can seizures be the sole manifestation of meningitis in febrile children? Pediatrics

1993;92:527‐34 14. Haeusler GM, et al. Question 1. Do febrile convulsions cause CSF pleocytosis? Arch Dis Child 2012; 97(2): 172‐5 15. Hampers LC, Spina LA. Evaluation and management of pediatric febrile seizures in the emergency department.

Emerg Med Clin North Am 2011;29: 83 – 93. 16. Hirtz D, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, et al. Practice parameter: treatment of the child with a

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