the fitting child curriculum link: pmp6 the unconscious child diane williamson consultant emergency...
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The Fitting Child
Curriculum link: PMP6 The unconscious child
Diane WilliamsonConsultant Emergency MedicineAddenbrookes Hospital
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OutlineSeizures
Status epilepticus and the APLS treatment protocol
Febrile convulsions
HypoglycaemiaCausesTreatment/reversal
DKACerebral Oedema – recognition and emergency treatment
Local and National Guidelines
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Status Epilepticus generalised convulsion lasting 30min or longer or repeated tonic-clonic convulsions occurring over a 30 minute
period without recovery of consciousness between convulsions
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Treatment Guideline
Time 0ABCHigh flow O2Blood glucoseConfirm that it is an epileptic seizure
Consider pre-hospital treatments already given
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5 MinutesMidazolam 0.5mg/kg buccally
Or
Lorazepam 0.1mg/kg IV
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15 Minutes
Lorazepam 0.1mg/kg IV
Call for senior help
Prepare phenytion
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25 Minutes
Phenytoin 20mg/kg IV over 20 minutesOr (if on regular phenytoin)Phenobarbitone 20mg/kg IV over 5 minutes
Consider paraldehyde 0.8ml/kg after start of phenytoin
Inform ICU/Senior Anaesthetist
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25 Minutes
RSI with thiopental 4mg/kg IV
Transfer to PICU
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Febrile ConvulsionsConvulsions that occur when a child has a febrile illness
Usually self-limiting and not harmful
Age 6 months to 5 years (usually toddlers)
1 in 25 children
Recur in 1/3 and 1/100 develop epilepsy
Risk factors for recurrence<15 months of agefrequent feversimmediate family member with history of febrile seizures
Note – antipyretic agents do not prevent febrile convulsions and should not be prescribed specifically for this purpose
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Look for a focus of infection
ENT – ears, pharynxRespiratoryUrinary tractSkinConsider meningitis and encephalitis
Using antipyretics specifically to treat fever is not recommended and does not prevent further seizures
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Hypoglycaemia
Glucose <2.6mmol/L
Most common cause is insulin-dependent diabetes
Consider inborn errors of metabolism
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Treatment of Hypoglycaemia
Bloods - special samples are needed for glucose, lactate and metabolic screening
LiHep on icefluoride tubesbiochem
Glucose 10% glucose 2 ml/kg (2.5ml/kg for newborns)Glucose infusion
e.g.Glucose 5% 120mg/kg/hrMonitor glucose
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DKA
British Society for Paediatric Endocrinology and Diabetes DKA Guideline
DKA CalculatorFluid management
Cerebral Oedema
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Cerebral Oedema
HeadacheNeurologic (e.g. restlessness, irritability, drowsiness, incontinence)Decreasing HRIncreasing BPDecreasing SaO2Neurologic signs e.g. cranial nerve palsiesAbnormal posturingSeizures
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Management of Cerebral Oedema
Senior help and PICU referralCheck glucose (R/O hypoglycaemia)Hypertonic saline 2.7% 5ml/kg over 5-10minOrMannitol 20% 2.5-5ml/kg over 20minDecrease fluid replacement to ½ maintenanceCT head when stable
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Guidelines
NICE CG 137 The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (2012)
Appendix F: algorithms for Status epilepticus
British Society for Paediatric Endocrinology and Diabetes DKA Guideline (2011)
Update due 2014
BSPED DKA Calculator (2011)
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Seizures in Children
Questions?