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Emergency Management ofSeizures
Sarah A. Murphy, MDPediatric Critical Care Fellow, M!
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• This presentation will review emergency
management of seizure/convulsions
• We will begin with a review of the approach
to a child who presents with: – lethargy
– unconsciousness OR
– convulsions/seizures
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ssess for !oma or !onvulsions:
"#$• %s the child:
– lert&
– Responding to "oice&
– Responding to #ain&
– $nconscious&
• child who is not alert but responding to voice islethargic
• child who does not respond to pain isunconscious
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$nconscious or !onvulsion:
• 'anage irway
• (ive diazepam or paraldehyde if convulsing
• #osition unconscious child
• (ive %" glucose:
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Obtain )istory:
• *ever&
• )ead %n+ury&
• ,rug or To-in e-posure&
• .irth asphy-ia or in+ury if newborn&
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-amination:
• "#$ score
• (eneral:
– #allor – 0aundice
– dema
– #etechial Rash
• )ead and 1ec2: – 3tiff nec2
– 3igns of trauma – #upilary reactions
– *ontanelle
– #osture
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4aboratory %nvestigations:
• .lood glucose
• .lood smear for malaria
• .lood pressure
• $rine microscopy
• lectrolytes
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,ifferential ,iagnosis of 4ethargy5
$nconscious5 or !onvulsions:• 'eningitis: irritable5 stiff nec2 or bulging fontanelle5
petechial rash
• !erebral 'alaria: +aundice5 anemia5 pallor5 convulsions5hypoglycemia
• *ebrile convulsions: history of same5 seziure associatedwith fever5 age 6 mos to 7 years5 normal blood smear
• )ypolycemia: responds to treatment with glucose5 chec2for malaria
• )ead in+ury: signs of trauma
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,ifferential ,iagnosis of 4ethargy5
$nconscious5 or !onvulsions:• #oisoning: suggested by history
• 3hoc2: unli2ely to cause seizures5 poor capillaryrefill5 rapid wea2 pulse
• (lomerulonephritis with encephalopathy:raised .#5 edema5 decreased urine5 blood in urine
• ,8: high blood sugar5 polydipsia and polyuria5deep breathing
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,ifferential ,iagnosis of lethargy5
unconsciousness or convulsions %1
1O1T
• .irth sphy-ia: difficult delivery5 onset in 9st
three days of life• %ntracranial hemorrhage: lowbirth weight
or preterm infant with onset in 9st three days oflife
• )emolytic disease of newborn/2ernicterus: +aundice5 pallor5 bacterialinfection5 onset in 9st three days of life
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,ifferential ,iagnosis of lethargy5
unconsciousness or convulsions %1
1O1T
• 1eonatal tetanus: onset from ;9
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mergency 'anagement of
3eizures&
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Clinical Diagnosis of Seizure
" Altered Mental Status
" !ypotonia
" Emesis
" Eye de#iation
" $onic%clonic mo#ements" &ncontinence
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Pathophysiology of Seizures
" Cellular Mechanisms responsi'le for Status
Epilepticus
" (atural progression of Status Epilepticus
" Systemic complications of Status Epilepticus
" (europathology" C(S mechanisms for neuronal damage)death
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Cellular Mechanisms
" A group of neurons in the C(S 'ecomedepolarized with a'normal synchrony andfire action potentials repetiti#ely,interfering with normal 'rain function
" $his a'normal paro*ysmal acti#ity isintermittent and usually self%limited,
lasting seconds to a few minutes
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Cellular Mechanisms
" Cellular e*planation li+ely multifactorial- &ncreased release of e*citatory
(eurotransmitters lutamate/- Decreased release of inhi'itoryneurotransmitters A0A/
- &ncreased)decreased neurotransmitter
sensiti#ity- Changes affecting ionic and #oltage%gatedchannels at neuronal synapses mem'raneinsta'ility
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(atural !istory of SE
" As the duration of SE progresses, there is adistinct e#olution with predicta'le effects in the
human 'ody
" Systemic changes occur in phases- Phase & 123 mins/
- Phase && 23%43 mins/ - se#ere systemic distress
- Phase &&& 543 mins/ - 6efractory SE
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Systemic Complications of SE
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Systemic Complications of SE (Rogers, ch.22)Parameter Early Late Complications
.lood #ressure )ypotension
rterial o-ygen )ypo-ia
rterial !O= %ncreased %!#
3erum p) cidosis
Temperature *ever utonomic activity rrhythmias
4ung fluids talectasis
3erum 8 > rrhythmias3erum !#8 Renal failure
!erebral blood flow !erebral bleed
!erebral O= consumption %schemia
)nl
nl
7338 9338
2338 2338
:3! 93!
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(europathology
Autopsy findings include- !ippocampal necrosis- ;idespread cere'ellar necrosis
- Degeneration of Pur+in
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(eurologic Damage
" &n animal models, irre#ersi'leneurologic damage in 73%:93 mins
" ;ith prolonged tonic%clonic acti#ityhypo*ia, hypoglycemia, hyper+alemia,hyper+alemia, increased &CP
" E#en with control of 0P, o*ygenation,#entilation, glucose and fe#er,neuronal cell death occurs
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!ypothesized C(S mechanismsof neuronal damage)death
" E*cessi#e presynaptic release of e*citatorytransmitter intracellular postsynaptic
changes
dendritic swelling and cell death." &nhi'itory%e*citatory interaction o#er%e*citation com'ined with decrease ofA0A%mediated inhi'ition.
" Possi'le unmas+ing of e*citatory glutamatereceptor channel%mediated e#ents
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&nitial Emergency Management
of Seizures" Sta'ilize the patient
" Address underlying causes of seizure
" $reat seizures
" Choices of anti%epileptic drugs
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Stabilize the patient
Maintain Cardio#ascular and 6espiratoryFunction
" airway protection" maintain #entilation, o*ygenation
" support circulation
" esta'lish #ascular access
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Sta'ilize the patient
" Position the patient to a#oidaspiration, suffocation, physical
in
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Sta'ilize the patient
Assess A, 0, C, D>s ??
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Sta'ilize the patient
- Airway protection" :338 o*ygen on all patients
" attempt to open airway with
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Sta'ilize the patient
- 0reathing" support 'y using muscle rela*ation if
necessary
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Sta'ilize the patient
- Circulation" #erify good 0P
" secure P&" (S 93cc)+g
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Sta'ilize the patient
- De*trose" Chec+ 'lood sugar
" &f suspecting low 'ood sugar, gi#e 9B8de*trose in water, 9%ml)+g
" :3 m)+g D:3 in neonates
6S& for Status Epilepticus
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6S& for Status Epilepticus
A&6;A- Airway o'struction
- oss of cough)gag- !ypo#entilation- !ypo*emia- 6is+ of aspiration
Preo*ygenate w) :338 =9 a#oid PP/
Atropine 3.39mg)+g 3.:mg min%:mg ma*/
Cricoid pressure
Sedati#e%$hiopental 2%Bmg)+g or
%ersed 3.3B%3.:mg)+g or%Pro ofol :%2m )+
Paralytic%Succinylcholine :%9mg)+g or
%ecuronium 3.:%3.2mg)+g
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Address underlying causes
" Elicit uic+ history- $rauma
- Antecedent illness
- Fe#er- &ngestion
- S+ipped meds
" ='tain critical la's- Chem G, Ca, Phos, C0C, to* screen, AED
le#els
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- Correct and then pre#ent meta'olicderangements
" !ydration
" Electrolytes
" lucose
" actate
Address underlying causes
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Common Causes of Seizures
" Fe#er
" !ypoglycemia
" !ypo*ia" Poisoning
" !ead $rauma" Meningitis
" &diopathic
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$reat Seizures
:. E#aluate and treat underlying cause
9. Stop clinical)electrical seizure acti#ityusing Anti%Epileptic Drugs/
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$he longer the seizure, the more
difficult to control so?AC$ FAS$H
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" owenstein and Alldredge- Seizures stopped 'y :st line therapy in
I38 of patients if started in the :st 23mins
- 0ut :st line drugs stopped seizures in only38 of patients if started 5 9hrs afterseizure
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&mplementing Drug $herapy
J&t>s not the particular choice of drug 'ut rather the timing,route, and #igor of therapy that are ma
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&mplementing Drug $herapy
" Anticipate conseuences of therapy- 6espiratory depression
- !ypotension
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Anticon#ulsants 0ased on a#aila'ility" First%line
" Diazepam, or orazepam
" Paraldehyde
" Second%line" Phenytoin or" Pheno'ar'itol
" $hird%line" $hiopental" Midazolam" &soflurane" Propofol
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Diazepam alium/
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Diazepam alium/" Can 'e administered &)P6
" A#oid repeated doses accumulation of drug and meta'olites
" Pharmaco+inetics - !ighly lipid%solu'le easily passes across 'lood 'rain 'arrier, and large
#olume of distri'ution
" 6apid distri'ution into 'rain :3 sec/" CSF concentrations reach L ma*imum #alue in 2 minutes" $hen, with redistri'ution, rapid drop in serum concentration
" Pharmacodynamics" Depresses all le#els of the C(S, including the lim'ic and
reticular formation 'y 'inding to the 'enzodiazepine site onthe gamma%amino'utyric acid A0A/ receptor comple* andmodulating A0A, which is a ma
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Paraldehyde
" Can be given:- I: $he usual intramuscular dose of paral!ehy!e for
status epilepticus is 3.:B to 3.2 ml)+g. Can gi#e additionaldose 3.3B ml)+g/. $he dose may 'e repeated in 9 to 4hours and no more than B milliliters should 'e administeredin one site AMA Department of Drugs, :7I4/.
- I": #) $he usual dose 3.: to 3.:B ml)+g. $he intra#enoussolution should 'e well%diluted in normal saline. !igherdoses 3.2ml)+g increase the incidence of ad#erse effects
2) Administration of intra#enous paral!ehy!e is notrecommended- %R: $he usual rectal dose is %I ml diluted with an eual or
dou'le amount of oil or isotonic sodium chloride. $heparal!ehy!e should 'e diluted 9: in oli#e or cottonseed oilor mi*ed in 933 ml of (S. 6ectal a'sorption is slow and
pea+ plasma le#els will not occur for 9 to hours Coniglio arnett, :7I7/.
P ld h d
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Paraldehyde
Pharmaco+inetics - Meta'olism 'y &E6, G38 to I38, with the rate of elimination slowed
'y hepatic insufficiency ilman et al, :7IB/
Pharmacodynamics =nset intramuscular 9 to 2 minutes, oral :3 to :B minutesPea+ 6esponse intramuscular B to :B minutes
Nse%aral!ehy!e is a rapidly acting hypnotic, with sleep normallyensuing in :3 to :B minutes. &t has no analgesic properties and mayproduce e*citement or delirium in the presence of pain.%aral!ehy!e is effecti#e for all types of con#ulsions and delirium athigh doses. 6espiratory depression and hypotension also occur inhigh doses, 'ut little effect on respiration and 'lood pressureoccur at therapeutic doses ilman et al, :7IB/.
Ati /
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orazepam Ati#an/" i#en o#er 9 minutes
" may repeat Q:3 mins * 9" 0eware of tachyphyla*is with successi#e doses
" Pharmaco+inetics" ipid%solu'ility and #olume of distri'ution half that of diazepam" !alf%life twice that of diazepam" onger onset of action 9 mins/
" Pharmacodynamics" Depresses all le#els of the C(S, including the lim'ic and reticular formation,
'y 'inding to the 'enzodiazepine site on the gamma%amino'utyric acid
A0A/ receptor comple* and modulating A0A, which is a ma
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Pheno'ar'ital
" Pharmaco+inetics
- $he least lipid%solu'le- Pea+ 'rain concentration 43 minutes- Predicta'le elimination +inetics- ery long half%life up to :93 hrs
" Pharmacodynamics- &nhi'its reticular acti#ating system interferes w) (A,
transport across mem'ranes/- =nset of action 93 minutes- Duration of action 9%I hours- 0eware of prolonged sedation, respiratory depression
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Dilantin Phenytoin/
" Pharmaco+inetics
" ow lipid solu'ility, enters 'rain slowly" Pea+ 'rain drug concentration :3%23 mins" Side effects hypotension, cardiac arrythmias" Cannot 'e gi#en with glucose will precipitate/
" Pharmacodynamics
- Sta'ilizes neuronal mem'ranes and decreases seizure acti#ity 'yincreasing efflu* or decreasing influ* of sodium ions across cellmem'ranes in the motor corte* creating delay in neuronal electricalreco#ery
- Prolongs effecti#e refractory period and suppresses #entricular pacema+erautomaticity, shortens action potential in the heart" Selecti#ely 'loc+ing the neurons that are firing at high freuency
" Pre#ents the electrical spread of a focus of irrita'le tissue
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Dilantin Phenytoin/
" (ot water%solu'le, dissol#ed in propylene glycol" =r 'enzoic acid 'enzoate/, a meta'olite of 'enzyl alcoholT
large amounts of 'enzyl alcohol which has 'een associatedwith a potentially fatal to*icity Ugasping syndromeU/ in
neonatesT meta'olic acidosis, respiratory distress, gaspingrespirations, C(S dysfunction including con#ulsions,intracranial hemorrhage/, hypotension and cardio#ascularcollapse
" $o*icity depends on the route of administration, duration,
e*posure, and dose- !ypotension, 'radycardia, arrhythmias, cardio#ascular collapse
especially with rapid &.. use/
- 6is+ of necrosis and lim' ischemia from infusion purpleglo#e syndrome/
Fos/phenytoin
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/p y
" Fosphenytoin is pro%drug of phenytoin hydrolyzed into phenytoin/
" Pharmaco+inetics
" ow lipid solu'ility, enters 'rain slowly" Pea+ 'rain concentration in 93%43 mins" !epatic meta'olism P%B3 system/
" Pharmacodynamics" Sta'ilizes neuronal mem'ranes flu* of (a, Ca ions/" =nset of action :3 mins
" Duration of action 9 hrs w) single dose" Does (=$ depress respiratory dri#e or alter MS" $o*icity depends on rate of administration not dose
- 'radycardia, hypotension, cardiac arrhythmia- Monitor !6, 0P, EC during D- A#oid e*tra#asation flush w) (S, use large P&/
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&ncidence of Status Epilepticus
" Status Epilepticus SE/ seizure that lasts forgreater than 23 mins or multiple seizures going onfor 23 mins without return to 'aseline in 'etween
" Status Epilepticus occurs as :st seizure in :98 ofchildren with seizures
" 6efractory Status Epilepticus 6SE/ Seizuresthat do no respond to :st line therapy and persistfor 5 43 minutes
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6efractory Status Epilepticus
" &nadeuate drug treatment
" Nncorrected medical and meta'olic complications- Meta'olic acidosis- Electrolyte im'alance- !ypoglycemia- &nfections- !yperthermia
" arge cere'ral lesion
% !ypercar'ia
% Fluid &m'alance
% Pulmonary Edema
% 6enal Failure% D&C
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$herapy for 6efractory SE
" $herapeutic o'
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Pento'ar'ital
- Directly depresses neuronal acti#ity through enhancedA0A receptor responses
- More lipid solu'le than Pheno'ar'ital penetrates 'rainfaster, redistri'ution into 'ody tissues
- Elimination half%life :B%43 hrs
- !ypotension is significant complication
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Drugs that Cause Seizures
" Antimicro'ials- &soniazid- Penicillins
- (alidi*ic acid
- Metronidazole
" Psychopharm drugs
- Antihistamines- Antidepressants
- Antipsychotics
- Phencyclidine
- $CA
" Anesthetics% !alothane% Enflurane% Cocaine
" (arcotics% Fentanyl% Meperidine
" Analgesics% etamine
$ t t i 6 l ti t
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$reatment in 6elation toAge
" (eonates- Nnpredicta'le relationship 'etween dose and theraputic
drug effect" ess protein 'inding
" aria'le a'ility to eliminate drug- orazepam Pheno'ar' fosphenytoin
" &nfants
- 0e ready to intu'ate- Pheno'ar'ital elimination half%life E6 long- %B days to reach steady%state- J$herapeuticK le#el V what wor+sH
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Simple Fe'rile Seizures" =ccurs with fe#er in a child aged 4 months to B years" A con#ulsion associated with an ele#ated temperature greater
than 2IWC" Single seizure
" ast less than :B minutes, ha#e no focal features, and, if theyoccur in a series, the total duration is less than 23 minutes." $he child is otherwise neurologically healthy and without
neurological a'normality 'y e*amination or 'y de#elopmentalhistory
" (o central ner#ous system infection or inflammation" (o acute systemic meta'olic a'normality that may producecon#ulsions
" (o history of pre#ious afe'rile seizures
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Management of :st non%fe'rile
seizure" &f well%appearing in ED, patient can
'e discharged to home
" =utpatient EE and M6& within :month
" =utpatient (eurology Consult
" =nly 238 will ha#e second seizure
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$a+e !ome Points
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$a+e !ome Points" $he longer the seizure, the more difficult it 'ecomes to stop so?AC$ FAS$H
" $he endpoint is (=$ a particular drug concentration 0N$ rather a clinicaland)or electrical endpoint.
" &t is not the particular choice of drug 'ut rather the timing, route and #igorof therapy that determines mortality and mor'idity.
" Early therapy is far more effecti#e that later therapy.
" 6ate of administration of a drug is more important than total amountadministered in terms of to*icity.
" &ntu'ate earlyT do not wait for florid systemic complications to occur.
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