pediatric neurologic emergencies may 2002 core rounds
TRANSCRIPT
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pediatric neurologic pediatric neurologic emergenciesemergencies
may 2002 core rounds
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contentscontents
seizures– approaches to
febrile seizure new onset non-febrile seizure established seizure disorder with recurrence neonatal seizures status epilepticus
– investigation, treatment, disposition headache
– discussion (as little evidence to support) migraine treatment imaging indications
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case 1case 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
– sick looking child
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case 2case 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?
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case 3case 3
16 year oldknown seizure disorder, on phenytointypical seizure presenting complaintV/S N, neuro N, otherwise looks well
approach?
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case 4case 4
2 week old parents - “doesn’t 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?
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definitionsdefinitions
febrile seizure – NIH defn - event of infancy/childhood, typically between age 3mo and 5yrs, with no evidence intracranial infection or defined cause
epilepsy - two or more seizures not provoked by a specific event such as fever, trauma, infection, or chemical change
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definitionsdefinitions
neonatal seizure – in first 28 days of life (typically first few days)
status epilepticus– seizure lasting >30 mins
NB rosen 5-10 mins
– sequential seizures without regain LOC >30min
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classificationclassification
generalized – LOC– tonic, clonic, tonic-clonic, myoclonic, atonic, absence
partial – focal onset– simple partial – no LOC– complex partial – LOC– partial secondarily generalized
unclassified
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etiologyetiology
infectiousmetabolictraumatictoxicneoplasticepilepticother
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differential diagnosisdifferential diagnosis
syncopebreath holdingsleep disorders (eg. narcolepsy)paroxysmal movement disorder
– tics,tremors
migrainespsychogenic seizures
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approach to febrile seizuresapproach to febrile seizuresthe numbersthe numbersepidemiology
– age 3mo – 5yrs– peak age 9-20 mo– 2-5% children will have before age 5– 25-40% will have family history– 80 – 97% simple– 3 - 20% complex
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simple febrile seizuresimple febrile seizure
< 15 minsno focal featuresno greater than 1 episode in 24hneurologically and developmentally normal
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complex febrile seizurecomplex febrile seizure
>15 min– febrile epilepticus >30min or recurrent without
regaining consciousness > 30min
focal recurrence within 24h
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what do parents want to what do parents want to know?know? recurrence
– risk recurrence 25-50%– risk recurrence after 2nd – 50%– most recurrences within 6-12 mo
(20% within same febrile illness)
risk of epilepsy– 2-3% (baseline 1%)– increased in
family history of epilepsy abnormal developmental status complex febrile seizure
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neonatal seizureneonatal seizure
brief and subtle– eye blinking– mouth/tongue movements– “bicycling” motion to limbs
typically sz’s can’t be provoked/consoledautonomic changesEEG less predictable
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neonatal seizureneonatal seizure
etiology– hypoxic-ischemic encephalopathy
Presents within first day
– congenital CNS anomalies– intracranial hemorrhage– electrolyte abnormalities – hypoglycemia and
hypocalcemia– infections– drug withdrawal– pyrodoxine deficiency
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status epilepticusstatus epilepticus
definition– deizure lasting >30 mins
NB Rosen 5-10 mins
– sequential seizures without regain LOC >30min
mortality in pediatric status epilepticus 4%morbidity may be as high as 30%
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SE treatment considerationsSE treatment considerations
ABC’sbrief directed Hx and Px
glucose antibiotics/antivirals
– if meningitis/encephalitis considered
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SE treatmentSE treatment
1st line anticonvulsants– IV
lorazepam 0.1mg/kg diazepam 0.2 mg/kg midazolam 0.2 mg/kg
– rectal diazepam 2-5 yrs – 0.5 mg/kg 6-11 yrs – 0.3 mg/kg >12 yrs – 0.2 mg/kg
– IM, intranasal, buccal midazolam
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SE treatmentSE treatment
2nd line agents– phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min)– fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150
mg/min)
3rd line agents– phenobarbital 20mg/kg @ 100mg/min– repeat prn 5-10mg/kg– maximum 40 mg/kg or 1 gram
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refractory SE treatmentrefractory SE treatment
consider midazolam– 0.2 mg/kg bolus– then 1-10 mcg/kg/min infusion
induce barbiturate coma– pentobarbital 5-15 mg/kg @ 25 mg/min– then 1-5 mg/kg/hour
others– valproic acid– paraldehyde, chloral hydrate– propofol, inhalational anesthesia, paralysis– lidocaine
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approach – stable post szapproach – stable post sz
history– pre-seizure
what was child doing when attack occurred precipitants – fever, trauma, poisoning, drug/med use aura
– deizure what movements – incl. eyes how long LOC? consequences – resp distress, incontinence, injury
– post seizure Post-ictal
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approach to stable patientapproach to stable patient
physical directed towards– systemic disease– infection– toxic exposure– focal neuro signs
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laboratorylaboratory
blood glucose? electrolytes? magnesium, calcium?
anything at all? what about first time seizures? recurrent?
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laboratorylaboratory
yes if…– neonatal– abnormal mental status persistent– diabetics, renal disease– diuretic use– dehydration– malnourishment
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laboratorylaboratory
septic work-up (CBC, BC, urine C+S, CXR, LP)– 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?
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lumbar puncturelumbar puncture
patients at greatest risk for meningitis– under 18 months of age– seizure in the ED– focal or prolonged seizure– seen a physician within the past 48 hours
other indications– concern about follow-up– prior treatment with antibiotics
The American Academy of Pediatrics “strongly consider” in infants under 12 months of age with a first
febrile seizure
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neuroimagingneuroimaging
WHO? which patients?
WHAT? CT vs. MRI– ultrasound in neonates
WHEN? emergent vs. elective
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ACEP guidelines - >6 yoACEP guidelines - >6 yo
consensus indication for non-contrast CT first time seizure patients
– if suspect structural lesion – partial onset seizure– age > 40– no other identified cause
recurrent seizure patients– change in pattern– prolonged post-ictal period– worsening mental status
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neuroimagingneuroimaging predictors of abnormal findings of computed tomography of the head in
pediatric patients presenting with seizures
Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23 – retrospective case series– predicts CT scan results normal if
no underlying high-risk condition – malignancy, NCT, recent CHI, or recent CSF shunt revision
older than 6 months sustained a seizure of 15 minutes or less no new-onset focal neurologic deficit
– not prospectively validated
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emergent EEG?emergent EEG?
not generally available on emergent basisbut consider in..
– persistent altered mental status (?non convulsive status epilepticus)
– paralyzed patients– pharmacologic coma
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dispositiondisposition
can be discharged home if– single seizure– stable, returning to baseline neuro status– no underlying condition/cause requiring
treatment in hospital– arranged follow-up
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EEG – 1EEG – 1stst non-febrile seizure non-febrile seizure
follow-up EEG– within 24h
Lancet 1998;352:1007-11 improved pick-up 51% vs 34% ? how soon do we get ours ?
– inter-ictal EEG’s often normal neuro may do sleep deprivation study (provocation)
– absence epilepsy and infantile spasms are invariably associated with an abnormal EEG
– spike and wave 3HZ
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idiopathic seizureidiopathic seizure
recurrence risk stratification – normal EEG – 25%– abN EEG – 60%– 2nd seizure – 75%
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neuroimagingneuroimaging
MRI superior
not emergently available
?defer imaging until follow-up MRI available in low risk patients?
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treatmenttreatment
correct underlying pathology, if any antipyretics ineffective in febrile seizure anti-epileptic choice often trial and error
no anti-epileptic 100% effective febrile seizure – diazepam, phenobarbital, valproic acid
– Currently AAP does not recommend neonatal - phenobarbital generalized TC – phenytoin, phenobarbital, carbamazepine, valproic
acid, primidone absence – ethosuximide, valproic acid new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate,
tiagabine, vigabatrine
in consultation with neurologist
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pediatric headachepediatric headache
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case 5case 5
14 year old mother’s 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?
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classificationclassification
classify based on temporal pattern
acute headaches– any febrile illness, sinus/dental infection, intracranial
infection/bleed (AVM,SAH,trauma) acute recurrent chronic progressive chronic non-progressive
– tension, psychogenic, post-traumatic, ocular refractive error
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acute recurrent headacheacute recurrent headache
migraine
other– cluster headache – typically >10 yo– sinusitis– vascular malformation
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migraine - terminologymigraine - 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 equivalent/”complicated migraine”– transient neuro deficits– +/- headache
migraine variants– Cyclic N/V, abdo pain– BPV
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migraine treatmentmigraine treatment
very little supporting evidence for pharmacologic treatment in children compared to adults
classes of medication– acetaminophen– NSAIDS– phenothiazines (dopamine antagonists)– dihydroergotamine– triptans
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the simple stuffthe simple stuff
acetaminophen 15 mg/kg PO 30mg/kg PR ibuprofen 10 mg/kg PO
Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of migraine in children: A double-blind, randomized, placebo-controlled, crossover studyNeurology 48:103-107, 1997 – N = 88 age 4-16– relief at 2 hours
acetaminophen 54% ibuprofen 68%
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other NSAIDSother NSAIDS
naproxen 5-7 mg/kg PO– no pediatric evidence
ketorolac IV 0.5 mg/kg (max 30mg dose)– not studied in pediatric migraine– not approved <16 yo– 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
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dihydroergotaminedihydroergotamine
not approved?dose – 0.1 – 0.5 mg IVnot studied in emergency population
Linder SL – Treatment of childhood migraine with dihydroergotamine mesylate Headache - 1994 Nov-Dec; 34(10): 578-80 – N = 30– inpatient protocol– IV DHE and PO metoclopramide – average 5 doses!– 80% response
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phenothiazinesphenothiazines
again no studies
metoclopramide 1-2 mg/kg IV (max 10mg)prochloperazine 0.1 – 0.15 mg/kg
IV/IM/PO/PR (max 10mg)
children may be more susceptible to EPS– ? pre-treat with benadryl
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triptanstriptans
mostly studied in adolescent groups sumitriptan subcutaneous 0.06mg/kg
– Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50 consecutive 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– long term treatment studies done– no emergent studies
triptans PO– studies plagued by high placebo response
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chronic progressive headachechronic progressive headache
least common presentation
most worrisome for increased ICP– pseudotumor cerebri– space occupying lesion
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imaging indications? discussimaging indications? discuss
lack of evidence to help– small studies lack power to guide decision
making
MRI preferred in non-urgent indication
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imaging indications? discussimaging indications? discuss
classically based on historical and physical– sudden severe headache– rapid increase over days - weeks– chronic progressive– suggestive of increased ICP
severe nocturnal headache (wakes or upon waking), changes in pain with position, coughing
– following head trauma– persistent neuro findings
? include migraine equivalents ?
– growth abnormality– age (? <3 ?)