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
Edward P. Sloan, MD, MPH, FACEP2
Attending Physician Attending Physician Emergency MedicineEmergency Medicine
University of Illinois Hospital
Our Lady of the Resurrection Hospital
Chicago, IL
Edward P. Sloan, MD, MPH, FACEP3
Edward P. Sloan, MD, MPH, FACEP4
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
Edward P. Sloan, MD, MPH, FACEP5
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%)
Edward P. Sloan, MD, MPH, FACEP6
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
Edward P. Sloan, MD, MPH, FACEP7
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
Edward P. Sloan, MD, MPH, FACEP8
Case #1:Case #1: Seizing infant, no IV accessSeizing infant, no IV access
• What therapies can be given?
• By what route?
• With what effect?
Edward P. Sloan, MD, MPH, FACEP9
Case #1Case #1
HxHx• 9 month old
• Febrile illness at home
• Seizing for paramedics
• Arrives in arms of CFD
• No IV access in field
Edward P. Sloan, MD, MPH, FACEP10
Case #1Case #1
PxPx• Hyperpyrexia, abn vital signs
• Actively seizing, generalized
• Tonic-clonic motor activity
• Cardiopulm exam OK
• No IV access available
Edward P. Sloan, MD, MPH, FACEP11
Case #1Case #1
DxDx• What are the diagnoses in this
child?
Edward P. Sloan, MD, MPH, FACEP12
Case #1Case #1
DxDx• Generalized convulsive status
epilepticus (GCSE)
• Complex febrile seizure
Edward P. Sloan, MD, MPH, FACEP13
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
Edward P. Sloan, MD, MPH, FACEP14
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
Edward P. Sloan, MD, MPH, FACEP15
Case #2: Case #2:
Pediatric SEPediatric SE
• How do we diagnose ped SE?
• What is the optimal Rx protocol?
• Why?
Edward P. Sloan, MD, MPH, FACEP16
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
Edward P. Sloan, MD, MPH, FACEP17
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…”
Edward P. Sloan, MD, MPH, FACEP18
Case #2Case #2
PxPx
• 98.7 98/60 72 20
• Well hydrated
• CV, lung exams normal
• Neuro exam intact
Edward P. Sloan, MD, MPH, FACEP19
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
Edward P. Sloan, MD, MPH, FACEP20
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
Edward P. Sloan, MD, MPH, FACEP21
Case #2Case #2
DxDx• Repetitive episodes with AMS
• Associated autonomic signs
• Rule out generalized nonconvulsive status epilepticus – Complex partial status epilepticus
– Absence status epilepticus
Edward P. Sloan, MD, MPH, FACEP22
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
Edward P. Sloan, MD, MPH, FACEP23
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
Edward P. Sloan, MD, MPH, FACEP24
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
Edward P. Sloan, MD, MPH, FACEP25
Case #2Case #2
RxRx
• IV lorazepam
• IV valproate
• Transfer to Children’s for ICU observation
Edward P. Sloan, MD, MPH, FACEP26
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?
Edward P. Sloan, MD, MPH, FACEP27
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
Edward P. Sloan, MD, MPH, FACEP28
Case #3Case #3
PxPx• VS OK prior to seizure
• Chest: Clear
• CV: Reg without
• Neuro: Non-focal
• Generalized tonic-clonic seizure
Edward P. Sloan, MD, MPH, FACEP29
Case #3Case #3
DxDx• Generalized seizures
• Hx complex partial seizures
• Sub-therapeutic valproate level vs. break-thru seizure
Edward P. Sloan, MD, MPH, FACEP30
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
Edward P. Sloan, MD, MPH, FACEP31
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
Edward P. Sloan, MD, MPH, FACEP32
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
Edward P. Sloan, MD, MPH, FACEP33
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?
Edward P. Sloan, MD, MPH, FACEP34
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
Edward P. Sloan, MD, MPH, FACEP35
Case #4Case #4
PxPx
• Vitals OK
• Neuro: slightly post-ictal
• Exam otherwise normal
• Patient has a 2nd seizure in the ED
Edward P. Sloan, MD, MPH, FACEP36
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
Edward P. Sloan, MD, MPH, FACEP37
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
Edward P. Sloan, MD, MPH, FACEP38
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
Edward P. Sloan, MD, MPH, FACEP39
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?
Edward P. Sloan, MD, MPH, FACEP40
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
Edward P. Sloan, MD, MPH, FACEP41
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
Edward P. Sloan, MD, MPH, FACEP42
Case #5Case #5
Question # 1Question # 1
• What diagnostic tests are indicated at this point?
Edward P. Sloan, MD, MPH, FACEP43
Case #5Case #5
Question # 2Question # 2
Did this patient have a seizure? A. YesB. No
Edward P. Sloan, MD, MPH, FACEP44
Case #5Case #5
Question # 3Question # 3
Does the patient require admission for observation for possible new onset seizures?
A. YesB. No
Edward P. Sloan, MD, MPH, FACEP45
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
Edward P. Sloan, MD, MPH, FACEP46
Case #5Case #5
Question # 4Question # 4
• Is this repeat spell a seizure? • What type?
Edward P. Sloan, MD, MPH, FACEP47
Case #5Case #5
Question # 5Question # 5
• Does this AMS, motor activity require Rx?
• What Rx?
Edward P. Sloan, MD, MPH, FACEP48
Case #5Case #5
Question # 6Question # 6
• Does the patient require admission for observation for possible new onset seizures?
Edward P. Sloan, MD, MPH, FACEP49
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
Edward P. Sloan, MD, MPH, FACEP50
Case #5Case #5
Question # 7Question # 7
• What med is to be used for seizure control / SE termination?
Edward P. Sloan, MD, MPH, FACEP51
Case #5Case #5
Question # 8Question # 8
• What med is to be used once SE is terminated?
• Why?
Edward P. Sloan, MD, MPH, FACEP52
Case #5Case #5
Question # 9Question # 9
• How should the meds be given?
• Why?
Edward P. Sloan, MD, MPH, FACEP53
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
Edward P. Sloan, MD, MPH, FACEP54
Case #5Case #5
RxRx
• Lorazepam to Rx the acute sz
• IV phenytoin, fosphenytoin, valproate, phenobarbital are AED load options
• PRN meds during transfer
Edward P. Sloan, MD, MPH, FACEP55
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
Edward P. Sloan, MD, MPH, FACEP56
Case #5Case #5
DxDx
• New onset seizure/SE
• Complex partial seizure with secondary generalized seizure
• Hx migraine headaches
Edward P. Sloan, MD, MPH, FACEP57
Case #5Case #5
DxDx
Do you believe you could diagnose a seizure on an EEG?
A. Yes
B. No
Edward P. Sloan, MD, MPH, FACEP58
Edward P. Sloan, MD, MPH, FACEP59
Edward P. Sloan, MD, MPH, FACEP60
Edward P. Sloan, MD, MPH, FACEP61
Edward P. Sloan, MD, MPH, FACEP62
Edward P. Sloan, MD, MPH, FACEP63
Edward P. Sloan, MD, MPH, FACEP64
Edward P. Sloan, MD, MPH, FACEP65
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
Edward P. Sloan, MD, MPH, FACEP66
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
Edward P. Sloan, MD, MPH, FACEP67
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
Edward P. Sloan, MD, MPH, FACEP68
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??
ferne_aaem_france_2005_sloan_pedssz_fshow.ppt
04/21/23 02:09 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