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emergencies
may 2002 core rounds
contents
seizures
approaches to
febrile seizure
new onset non-febrile seizure
established seizure disorder with recurrence
neonatal seizures
status epilepticus
headache
discussion (as little evidence to support)
migraine treatment
imaging indications
case 1
2
year old
parents shaking episode lasting 10 mins
EMS called - child no longer shaking
V/S - BP 105/60 HR 100 RR 18 Sat N T39
approach?
well looking child
first event
multiple events
case 2
8
year old
parents describe good history for tonic-clonic activity
lasting 2 mins
1st event
post event confusion - improving
in ED - V/S N, N sensorium, N neuro exam
otherwise healthy, no meds, no allergies
approach?
case 3
16
year old
known seizure disorder, on phenytoin
typical seizure presenting complaint
V/S N, neuro N, otherwise looks well
approach?
case 4
2
week old
parents - doesnt look right, mouth opening and
closing
one episode lasting 1 minute
child not interested in feeding, sleepy
V/S - BP 90/50 HR 130 RR 38 sat N T 37.8
otherwise normal exam
approach?
definitions
febrile
epilepsy
definitions
neonatal
status
epilepticus
classification
generalized
LOC
tonic, clonic, tonic-clonic, myoclonic, atonic, absence
partial
focal onset
unclassified
etiology
infectious
metabolic
traumatic
toxic
neoplastic
epileptic
other
differential diagnosis
syncope
breath
holding
sleep disorders (eg. narcolepsy)
paroxysmal movement disorder
tics,tremors
migraines
psychogenic
seizures
15 mins
no focal features
no greater than 1 episode in 24h
neurologically and developmentally normal
min
within 24h
risk
of epilepsy
neonatal seizure
brief
and subtle
eye blinking
mouth/tongue movements
bicycling motion to limbs
typically
neonatal seizure
etiology
hypoxic-ischemic encephalopathy
hypocalcemia
infections
drug withdrawal
pyrodoxine deficiency
status epilepticus
definition
deizure lasting >30 mins
NB Rosen 5-10 mins
sequential seizures without regain LOC >30min
mortality
SE treatment considerations
ABCs
brief
directed Hx and Px
glucose
antibiotics/antivirals
if meningitis/encephalitis considered
SE treatment
1st
line anticonvulsants
IV
lorazepam 0.1mg/kg
diazepam 0.2 mg/kg
midazolam 0.2 mg/kg
rectal diazepam
SE treatment
2nd
line agents
mg/min)
3rd
line agents
refractory SE treatment
consider
midazolam
induce
barbiturate coma
others
valproic acid
paraldehyde, chloral hydrate
propofol, inhalational anesthesia, paralysis
lidocaine
deizure
post seizure
Post-ictal
directed towards
systemic disease
infection
toxic exposure
focal neuro signs
laboratory
blood
glucose?
electrolytes?
magnesium, calcium?
anything
at all?
what about first time seizures? recurrent?
laboratory
yes
if
neonatal
abnormal mental status persistent
diabetics, renal disease
diuretic use
dehydration
malnourishment
laboratory
septic
as indicated
sick child
< 12 - 18 mo
therapeutic
drug levels
other
ABG
toxicologic screen
TORCH, ammonia, amino acids in neonate
CPK, lactate, prolactin ?confirm seizure?
lumbar puncture
patients
other
indications
of Pediatrics
neuroimaging
WHO?
which patients?
WHAT?
CT vs. MRI
ultrasound in neonates
WHEN?
change in pattern
prolonged post-ictal period
worsening mental status
neuroimaging
emergent EEG?
not
disposition
can
be discharged home if
single seizure
stable, returning to baseline neuro status
no underlying condition/cause requiring
treatment in hospital
arranged follow-up
EEG
within 24h
Lancet 1998;352:1007-11
improved pick-up 51% vs 34%
? how soon do we get ours ?
idiopathic seizure
recurrence
risk stratification
neuroimaging
MRI
not
superior
emergently available
?defer
treatment
correct
in
neonatal - phenobarbital
generalized TC phenytoin, phenobarbital, carbamazepine, valproic acid,
primidone
absence ethosuximide, valproic acid
new anti-epileptics felbamate, gabapentin, lamotrigine, topiramate,
tiagabine, vigabatrine
pediatric headache
case 5
14
year old
mothers chief complaint - having headaches all the
time, getting worse, this is not normal!! etc. etc..
V/S N
looks in discomfort but otherwise well
approach?
treatment
imaging?
classification
classify
acute
headaches
infection/bleed (AVM,SAH,trauma)
acute
recurrent
chronic progressive
chronic non-progressive
tension, psychogenic, post-traumatic, ocular refractive
error
migraine - terminology
classic migraine
biphasic
neuro aura
headache, N/V, anorexia, photophobia
either unilateral (older) / bilateral(younger) or both
common migraine
malaise, dizziness, N/V, feels and looks sick
unilateral/bilateral
migraine variants
Cyclic N/V, abdo pain
BPV
migraine treatment
very
15 mg/kg PO 30mg/kg PR
ibuprofen 10 mg/kg PO
other NSAIDS
naproxen
5-7 mg/kg PO
no pediatric evidence
ketorolac
Houck CS Safety of intravenous ketorolac in children and cost savings with a unit
dosing system. J Pediatr - 01-Aug-1996; 129(2): 292-6
1747 children
0.2% hypersensitivity
0.1% renal complications (in patients with renal disease)
0.05% gi bleed
dihydroergotamine
not
approved
?dose 0.1 0.5 mg IV
not studied in emergency population
phenothiazines
again
no studies
metoclopramide
triptans
mostly
patients with acute migraine in a pediatric neurology office practice. Headache 36:419
422, 1996
N = 50 age 6-18
78% effective at 2 hours
6% recurrence
sumitriptan
intranasal
triptans
PO
common presentation
most
pseudotumor cerebri
space occupying lesion
of evidence to help
making
MRI
growth abnormality
age (? <3 ?)