pediatric prehospital seizure management: evidence based guidelines and state of care in co kathleen...
TRANSCRIPT
Pediatric Prehospital Seizure Management:
Evidence Based Guidelines and State of Care in CO
Kathleen Adelgais, MD MPHPediatric Emergency
MedicineChildren’s Hospital Colorado
Introduction
• Seizures are most common neurologic disorder in children
• About 5% of all children will have at least 1 seizure within first 16 years
• Up to 10% of ambulance calls for children are for seizure activity
• Approximately 1.5% of total ED visits by children are for seizure-related complaints
Pathophysiology
• Excess neuronal discharge activity within the brain: Increased glucose & O2 consumption
Increased CO2 & lactic acid production
• Initial autoregulatory mechanisms compensate with increased cerebral blood flow
• Brief seizures rarely produce any lasting effects
Pathophysiology
• Prolonged seizure activity can result: Lactic acidosis Rhabdomyolysis Hyperkalemia Hyperthermia Hypoglycemia Shock Pulmonary failure Permanent neuronal injury
• Permanent neuronal injury probably does not occur until status lasts for longer than 1 hr
Seizures in CO Prehospital Care
Make up approximately 10% of top 75% of prehospital callsTotal number of children: approximately 2300/yr
5
Proportion of benzodiazepines given
405 patients treated with benzodiazepines in prehospital settingMajority treated with Midazolam: 64%
6
N=405
Goals of Seizure Management
• Rapid stabilization of cardio-respiratory function
• Termination of clinical and electrical seizure activity
• Treatment of life-threatening precipitants
• Recognition & minimization of adverse physiologic consequences
Goals of Seizure Management
• Prehospital: Oxygen Glucose check and treatment Benzodiazepines Transport
8
PREHOSPITAL TREATMENT:EVIDENCE-BASED GUIDELINE
9
Lorazepam
• Historically used in ED setting
• Known respiratory depression and hypotension Less respiratory depression & fewer ICU
admissions in comparison to diazepam
• Duration of action: 12-24 hrs
• Dose: 0.1mg/kg IV/IO (max 4 mg)
Diazepam
• Historically used in prehospital setting Now seen in home treatment of seizures
• Respiratory depression, somnolence, hypotension, ataxia, bradycardia
• Duration of action: up to 4 hrs (redistributes from CNS quickly)
• Can be used both IV and rectally• IV/IO dose is 0.05 mg/kg to max of 5 mg• PR dose is 0.3 mg/kg to max of 10 mg
Midazolam
• Benzodiazepine with good efficacy to stop seizures
• Duration of action: 2-6 hrs• Can be given intravenously, intranasal,
and intramuscularly IV/IO/IM dose is 0.1 mg/kg to max of 5 mg IN dose is 0.2 mg/kg to max of 10 mg
• Note: For IN administration use the MAD Nasal™ for better drug delivery
Mucosal Atomization Device (MAD Nasal™)
• Great for use in prehospital setting
• Allows for non-parenteral drug delivery
• Great in pediatrics where IV access can be challenging
• Medications Fentanyl Naloxone Midazolam Cardiac medications Glucagon
Source: http://www.lmana.com
Prehospital: IN Midazolam vs PR Diazepam
• Study performed to compare IN Midazolam to PR Diazepam for prehospital treatment of pediatric seizures
• Groups were similar in: age, gender, seizure type
• PR Diazepam more likely to: Have continued seizure activity upon
arrival to ED Require BVM en route Require ICU admission after reaching
hospital
Prehospital: Midazolam IM vs. Diazepam PR
• Study comparing Diazepam PR to Midazolam IM
• Retrospectively reviewed 93 patient charts• Groups similar with regard to age, gender,
seizure type• No difference in:
Rates of termination of seizure activity Recurrence of seizure activity Need for additional treatment Need for hospitalization
• One difference: Trend toward need for intubation in IM midazolam group
Evidence Based Guideline for Prehospital Pediatric Seizure Management:Key Features
• Rapid check of glucose• Management of
hypoglycemia with Dextrose, Glucagon
• In setting glucose >60, goal is immediate cessation of seizure with NON-parenteral meds
• IN, Buccal, IM midazolam as 1st line treatment
• If long transport time, consider IV/IO access
• Reassessment for seizure activity after 5 minutes
• IV lorazepam• IV midazolam• IV diazepam• If no IV: dosing of
midazolam as mentioned above
Case Examples
• 6 year old with known seizures estimated weight of 20 kg given 2 mg IV midazolam
• 3 year old with seizure, estimated weight of 19 (Broselow) given 4 mg of IV midazolam
• 16 mo old with seizure, estimated weight of 10 kg, given 1 mg of IM midazolam, followed by additional 1 mg when seizure recurred
• 2 year old with seizure, estimated weight of 15 kg, given 1.5 mg IV midazolam
17
Additional Examples
• 8 yo with brain tumor, estimated weight of 42 lbs, given 2 mg IV midazolam
• 9 year old with seizures, no estimated weight, given 4 mg IV midazolam
• 3 year old with seizures x 10 min, estimated weight 20 kg (blue on Broselow), given 3.6 mg IM midazolam
• 3 year old with seizures, given 1 mg IN followed by 1 mg IM. No estimated weight documented
Quality Benchmarks for Prehospital Seizure Management
• ??????????????????????????????????