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


Attending Physician Attending Physician Emergency MedicineEmergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection Hospital

Chicago, IL



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


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%)


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


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


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

• What therapies can be given?

• By what route?

• With what effect?


Case #1Case #1

HxHx• 9 month old

• Febrile illness at home

• Seizing for paramedics

• Arrives in arms of CFD

• No IV access in field


Case #1Case #1

PxPx• Hyperpyrexia, abn vital signs

• Actively seizing, generalized

• Tonic-clonic motor activity

• Cardiopulm exam OK

• No IV access available


Case #1Case #1

DxDx• What are the diagnoses in this

child?


Case #1Case #1

DxDx• Generalized convulsive status

epilepticus (GCSE)

• Complex febrile seizure


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


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


Case #2: Case #2:

Pediatric SEPediatric SE

• How do we diagnose ped SE?

• What is the optimal Rx protocol?

• Why?


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


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…”


Case #2Case #2

PxPx

• 98.7 98/60 72 20

• Well hydrated

• CV, lung exams normal

• Neuro exam intact


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


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


Case #2Case #2

DxDx• Repetitive episodes with AMS

• Associated autonomic signs

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

– Absence status epilepticus


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


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


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


Case #2Case #2

RxRx

• IV lorazepam

• IV valproate

• Transfer to Children’s for ICU observation


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?


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


Case #3Case #3

PxPx• VS OK prior to seizure

• Chest: Clear

• CV: Reg without

• Neuro: Non-focal

• Generalized tonic-clonic seizure


Case #3Case #3

DxDx• Generalized seizures

• Hx complex partial seizures

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


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


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


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


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?


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


Case #4Case #4

PxPx

• Vitals OK

• Neuro: slightly post-ictal

• Exam otherwise normal

• Patient has a 2nd seizure in the ED


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


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


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


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?


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


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


Case #5Case #5

Question # 1Question # 1

• What diagnostic tests are indicated at this point?


Case #5Case #5


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


Case #5Case #5


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

A. YesB. No


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


Case #5Case #5


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


Case #5Case #5


• Does this AMS, motor activity require Rx?

• What Rx?


Case #5Case #5


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


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


Case #5Case #5


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


Case #5Case #5


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

• Why?


Case #5Case #5


• How should the meds be given?

• Why?


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


Case #5Case #5

RxRx

• Lorazepam to Rx the acute sz

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

• PRN meds during transfer


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


Case #5Case #5

DxDx

• New onset seizure/SE

• Complex partial seizure with secondary generalized seizure

• Hx migraine headaches


Case #5Case #5

DxDx

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

A. Yes

B. No









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


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


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


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

[email protected]@ferne.org

Edward P. Sloan, MD, MPH, FACEPEdward P. Sloan, MD, MPH, [email protected]

312-413-7490312-413-7490

http://www.ferne.org/

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