5/23/14
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Andi Marmor, MD, MSEd Associate Professor, Pediatrics University of California, San Francisco
Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments
Tesla is a previously healthy 16 mo girl BIB 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 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
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A. Obtain blood, urine and CSF cultures B. Admit for neurologic evaluation C. Obtain a head CT or MRI D. Obtain a stat EEG E. 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 status
Kimia, 2010; Fletcher 2013
Tesla 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
5/23/14
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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
A. Obtain blood, urine and CSF cultures B. Admit for neurologic evaluation C. Obtain a head CT or MRI D. Obtain a stat EEG E. Discharge when at neurologic baseline
Recurrence: 10-‐50% Younger age, family history, complex seizure, lower temp
Treat fevers appropriately for comfort only
5/23/14
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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, improving Pushes you away purposefully and symmetrically, and knows his name and age
A. Head CT B. Head MRI C. Complete H and P D. CBC and electrolytes E. 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
A. Head CT B. Head MRI C. Complete H and P D. CBC and electrolytes E. Lumbar puncture
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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 lorazepam B. IM lorazepam C. IM midazolam D. Rectal diazepam E. 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
5/23/14
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A. IV lorazepam B. IM lorazepam C. IM midazolam D. Rectal diazepam E. Buccal midazolam
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
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Febrile Seizures: No additional studies needed for SFS or CFS if neuro exam improving at 30 min and normal at 1 hour
Consider LP if: < 12 mo AND 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
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