SEIZURE IN INFANT AND CHILDREN BY AGH PAKNIYAT

• status epilepticus and neonatal seizures need emergent evaluation and treatment , while other seizure in children that are well may not needed completely evaluation in ED.

TYPES OF SEIZURE • Focal

• Generalized ; convulsive and non convulsive ; absence seizures (brief episode of staring without a postictal state) atonic seizures (sudden loss of muscle tone with a sudden “drop” to the floor) myoclonic seizures. Partial seizures ; Simple or Complex

Status Epilepticus : any “prolonged” seizure, or recurrent seizures lasting >5 minutes without return to full consciousness, is considered status epilepticus

Nonconvulsive status epilepticus may present as a prolonged postictal state and must be considered in any patient with altered mental status,

LAB TEST • bedside glucose on all pt.

• Additional laboratory evaluation : directed by the history and is not routinely indicated for febrile seizures or first-time afebrile seizures that are nonfocal in a child with a normal examination.

• electrolytes (including calcium)

• serum antiepileptic medication levels, toxicologic testing

• spinal fluid for evaluation of possible central nervous system infection

• Urine culture and analysis : febrile seizures in the child with fever and no identifiable source.

• Electrocardiogram

• Emergent electroencephalogram monitoring : refractory status epilepticus

IMAGING • Routine neuroimaging is rarely indicated or helpful : trauma or in the setting

of focal deficits.• Todd’s paralysis : temporary ; focal deficit of unknown etiology ; last up to 36

hours after a seizure. unilateral and lasts on average 15 hours; it can be bilateral and involve a patient’s speech or vision. Immediate Ct for R/o of Stroke or ICH.

• Most first-time seizures in the well-appearing child with a normal examination are best evaluated with outpatient MRI, which avoids ionizing radiation and provides better anatomic detail.

TREATMENT : PREHOSPITAL

• BNZ : IV , IN , Buccal , Rectal or intraosseous route• Diazepam Rectal ; Short half time • Midazolam is rescue drug , use IN• Lorazepam not useful in prehospital or at home , need IV line,

There is new evidence that intranasal lorazepam using a MAD® may be as effective as IV lorazepam in the treatment of status epilepticus.

TREATMENT OF STATUS EPILEPTICUS: ED• Administer oxygen by facemask • institute continuous pulse oximetry • cardiac monitoring• IV or intraosseus (IO) access• administer medication early via alternate routes (intranasal, IM, PR, buccal) if there

is IV delayed.• Obtain bedside glucose testing and electrolyte levels when available.• The decision to intubate is clinical :Intubate for apnea and persistent hypoxia. • Blood gas concentrations are not needed to guide the decision to intubate• arrange continuous electroencephalogram monitoring for intubated patients

with status epilepticus.

CONTINUE …

• First line :

• BNZ :

lorazepam is preferred .

if two doses of benzodiazepines not effective, additional doses are unlikely to be successful.

• fosphenytoin, levetiracetam, phenobarbital, or valproic acid are preferred second-line treatment choices.

• choose two of the four medications for refractory status epilepticus and then move on to a fourth-line treatment option if a seizure persists.

• Second and third line :• Fosphenytoin

is preferred as second-line treatment over phenobarbital except in neonates.

• it has a different mechanism of action from benzodiazepines and phenobarbital, which both bind gamma-aminobutyric-acid receptors.

• Monitor serum levels in patients with renal or hepatic dysfunction.

• Levetiracetameliminated solely via renal excretion and has no hepatic metabolism• it is commonly used for maintenance therapy for multiple

seizure types.

• Phenobarbitalused in neonates who are often maintained on daily phenobarbital for subsequent seizure control.• Side effects include sedation and cardiorespiratory

depression, which may be amplified by benzodiazepines

• Valproic acidtreatment of children already taking this medication who are suspected of having subtherapeutic levels.

• twenty to 40 milligrams/kg of IV valproic acid effectively terminates seizure activity with few side effects or less sedation.

• caution in children at risk for metabolic disease, because in rare cases it may cause hepatic failure

• has rarely been associated with thrombocytopenia

• Fourth-Line Treatment:• Propofol: effectively treat refractory status epilepticus better than

pentobarbital.• Slowly infused : bradycardia, apnea, and hypotension.

f propofol infusion syndrome: receiving sustained propofol administration (>24 hours) :

• Metabolic acidosis, rhabdomyolysis, renal failure, and cardiac failure

• pentobarbital coma:• respiratory depression, hypotension, and decreased

cardiac contractility, and most patients require intubation and inotropic support

• Midazolam infusion : less adverse effect but has a higher rate of seizure recurrence

• hypoglycemia : rapid infusion of 2 mL/kg of 25% dextrose in water or 5 mL/kg of 10% dextrose in water.

• hyponatremia : 3% NaCl 4 to 6 mL/kg over 20 minutes, or begin an infusion of 20 mL/kg of 0.9% NaCl if 3% NaCl is not immediately available. The sodium level should be rechecked after the bolus to determine whether a second bolus is necessary

• Hypocalcemia: Calcium gluconate 0.3 mL/kg over 5 to 10 minutes is preferred over calcium chloride when infusing through a small peripheral IV, as calcium chloride can cause local irritation.

• hypomagnesemia (serum magnesium <1.5 mEq/L) : magnesium sulfate 50 milligrams/kg IV infused over 20 minutes.

• Discharge : • Infants >6 months of age with febrile seizures • children with single seizures lasting <15 minutes who return to baseline

mental statusand have no focal neurologic deficits or secondary cause of seizure requiring.

• Children with prolonged seizures and those with refractory seizures requiring ED treatment who stop seizing should be observed for 24 hours and monitored for recurrence or side effects from medication.

SIMPLE FEBRILE SEIZURES

• no blood studies, neuroimaging, or electroencephalogram is necessary for most simple febrile seizures and the evaluation should focus on identifying the source of fever.

• Consider lumbar puncture : infants 6 to 12 months of age who are unimmunized for Haemophilus influenza type B or streptococcus pneumonia and those taking antibiotics, which can mask the signs and symptoms of meningitis

• Having a febrile seizure does not mean that a child will develop epilepsy; The overall risk of recurrence after a single afebrile seizure is about 40%.

FACTORS THAT INCREASE RISK OF RECURRENT SEIZURE:• family history of seizures, • multiple febrile seizures, • first febrile seizure before 12 months of age. • developmental delay• focal seizures• Todd’s paralysis• focal neurologic findings on examination• abnormal findings on electroencephalogram, CT, or MRI.

COMPLEX FEBRILE SEIZURES• seizures with fever that last >15 minutes, that recur within a 24-hour period,

are focal, or occur in children <6 months or >5 years of age without any signs of serious infection.

• Routine blood tests and imaging are not indicated, even in the setting of complex febrile seizure, if the child returns to baseline in the ED.

• Children with a prolonged seizure ;fever ; appear ill : undergo evaluation to rule out serious bacterial infection in the blood and cerebrospinal fluid , but not delay for AB.

• Although antipyretics are indicated in children with fever, there is no evidence that antipyretics can prevent subsequent febrile seizures

• If there is evidence that the child had vomiting or diarrhea, is dehydrated, or fails to return to baseline, laboratory tests are recommended.

• An electroencephalogram should be performed, the timing is unclear: an electroencephalogram within 24 hours of the seizure is most likely to show abnormalities; an electroencephalogram within 24 to 48 hours may also show some transient postictal slowing.

INDICATIONS FOR EMERGENT HEAD CT :

• Condition predisposing them to intracranial abnormalities,• with focal seizures• children younger than 33 months of age with new-onset

seizures.

• Outpatient MRI should be considered in any child with any of the following: • significant cognitive or motor impairment• abnormal findings on neurologic examination• abnormal electroencephalogram findings• partial seizure• infants <1 year of age.

NEONATE SEIZURE • Apparent life-threatening events ; pallor or cyanosis and a change in muscle tone • Regarneonates with witnessed seizures require extensive evaluation.• Obtain cultures of blood, urine, and cerebrospinal fluid and test for herpes simplex

virusand begin empiric parenteral antibiotics and acyclovir.

• Neonates with seizures are more likely to have electrolyte abnormalities than older children, and electrolytes including calcium and glucose should be measured

• Consider head CT for concerns of nonaccidental trauma, intracranial hemorrhage, infarction or mass (even without external signs of injury).

• Finally, if inborn errors of metabolism are suspected, obtain serum levels of lactate and ammonia, as well as serum amino acids and urine organic acids

• Treat the actively seizing neonate with benzodiazepines as with older children; consider phenobarbital for second-line therapy.

SEIZURE IN EPILEPTIC PATIENTS

• Subtherapeutic drug levels may result when a child outgrows a previously prescribed dose, vomits medications due to an intercurrent illness, starts a new medication (due to changes in drug pharmacokinetics from drug interactions), or does not adhere to the original drug regimen.

• Children with epilepsy may have a lower seizure threshold with febrile illness, even with therapeutic anticonvulsant levels, and the ED evaluation in these situations may be limited to determining the source of fever

SEIZURES IN CHILDREN WITH VENTRICULOPERITONEAL SHUNTS• underlying epilepsy, shunt malfunction, and central nervous system

infection.• radiographic ventriculoperitoneal shunt series • head CT or “quick brain MRI” to evaluate for increased ventricular size.• CNS infection : pediatric neurosurgeon should be consulted and the

shunt tapped for cerebrospinal fluid analysis and culture.• Consider prior shunt infections

SEIZURES IN TRAUMA

• “Impact seizures” (seizures that occur within minutes of head trauma)• seizures that occur in a more delayed fashion, however, are more indicative of

severe injuries.• Children with identified intracranial injury and a witnessed seizure should be

treated with a loading dose of antiepileptic medication, typically fosphenytoin 20 milligrams/kg IV, to prevent short-term recurrence that can worsen traumatic brain injury and increase intracranial pressure;

• benzodiazepines remain first-line treatment for active seizures in the setting of trauma.

• Maintain a high index of suspicion for trauma in the setting of afebrile seizures in infants.