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Emergency Setting
Edward P. Sloan, MD, MPH
Associate Professor
Department of Emergency Medicine
University of Illinois
Chicago, IL
Case
A 7-year old boy presents to the ED with a history of
staring spells, some shaking movements, and
headache over the past day. He has no history of
seizures or epilepsy. In the ED, he has three episodes
of tachycardia, staring and confusion that last several
minutes and resolve without therapy. He then has a
similar episode associated with diaphoresis and
urinary incontinence. His most likely diagnosis is:
Rectal diazepam
Rectal diazepam gel
IM midazolam
IV lorazepam
IV phenobarbital
Edward Sloan, MD, MPH
Case
A 13-year old female presents at mid-morning to the ED
with a one-day history of a frontal headache, consistent
with prior migraines, that was relieved with ibuprofen.
She also was noted by family members to be restless in
bed, and was noted to thrash about for a brief period of
time. The family denied that this was a generalized
seizure, and denied any history of epilepsy, trauma,
drug ingestion, or similar episodes. The patient has a
similar episode in the ED, and then has a generalized
seizure.
Edward Sloan, MD, MPH
Case
A 21-year old male college student presents
in the early morning to the ED with a oneday history of having a generalized seizure
upon awakening. The patient had been
partying after final exams, and had not
been getting much sleep for several days.
Over the phone, his mom noted that he had
a history of staring spells as a child.
Edward Sloan, MD, MPH
IV midazolam
IV phenytoin
IV fosphenytoin
IV valproate
IV phenobarbital
1-5 mg/kg
10-15 mg/kg
20-30 mg/kg
90-100 mg/kg
25 mg/L
50 mg/L
75 mg/L
100 mg/L
125 mg/L
Edward Sloan, MD, MPH
Overview
Global Objectives
Overview
Pediatric Sz Epidemiology
Common EMS & ED problem
Szs are up to 6% of EMS encounters
Up to 1% of all ED visits are peds sz
Peds febrile: 1 in 125 visits (0.8%)
Peds afebrile: 1 in 500 visits (0.2%)
Overview
Pediatric Sz Epidemiology
Overview
Pediatric Sz Epidemiology
Mean age 3.2 yrs, median age 1 year
61% by age 3
Etiology age dependent
25% is febrile SE
Before age 1, 75% due to acute insult
Epilepsy, fever, CNS infection common
Edward Sloan, MD, MPH
Pediatric Sz Etiologies
Meningitis
Hyponatremia
Cocaine Toxicity
Pediatric Seizures
Seizure Outcome
Immature CNS, myelinization
More prone to seizures
More resistant to consequences
Pediatric Seizures
SE Outcome
Based on CNS status prior to SE
Normal CNS, 64% remain intact
Mortality related to two factors:
Acute neurologic insult
Chronic CNS condition
Pediatric Seizures
Seizure Type Classification
Generalized
Involves both cerebral hemispheres
Convulsive: tonic-clonic seizures
Non-convulsive: absence seizures
Partial
Involves one cerebral hemisphere
Simple: no impaired consciousness
Complex: impaired consciousness
Edward Sloan, MD, MPH
Seizure Classification
Generalized Seizures
Convulsive seizures
Tonic sz: sustained contractions
Clonic sz: rhythmic flexor spasms
Tonic-clonic sz: combined movements
Non-convulsive
Simple absence: impaired consciousness
Complex absence: brief motor mvmts
Edward Sloan, MD, MPH
Seizure Classification
Partial Seizures
Simple seizures (no LOC)
Focal motor (Jacksonian)
Sensory or somatosensory
Autonomic
Psychic
Pediatric Seizures
Other Generalized Sz Types
Neonatal seizures
Benign childhood epilepsy (Rolandic)
Infantile spasms (West syndrome)
Lennox-Gastaut syndrome
Atonic seizures
Febrile seizures
Edward Sloan, MD, MPH
Pediatric Seizures
Status Epilepticus Types
Convulsive SE: tonic-clonic sz
Non-convulsive SE: no tonic-clonic sz
Absence SE
Complex partial SE
No frank coma
More common in children
Not always due to co-morbidity
Mortality ?? Not as high as in GCSE
Edward Sloan, MD, MPH
Seizure Therapy
Generalized Seizure Protocol
Benzodiazepines
PR diazepam, IM midazolam, IV lorazepam
Phenytoins
Fosphenytoin can be given IV or IM
Phenobarbital or valproate
Less sedation with valproate
Seizure Therapy
Ongoing Therapies
Absence:
Atonic:
Myclonic:
Partial:
Generalized:
ethosuximide, valproate
valproate, clonazepam,
ethosuximide
valproate, clonazepam
carbamazepine,
phenytoin, valproate
carbamazepine,
phenytoin, phenobarb,
primidone, valproate
Edward Sloan, MD, MPH
Case Presentation
ED Pediatric Seizure Cases
Pediatric complex partial SE
New onset SE in an adolescent
New onset sz in a college student
Pediatric SE
Hx
Pediatric SE
Hx (cont.)
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
Pediatric SE
Px
98.7, 98/60 72 20
Well-hydrated
CV, lung exams normal
Neuro exam intact
Pediatric SE
Clinical Course
0220 episode
Tachycardia, BP OK, airway OK
Confused, staring off into space
Episode lasted < 5 minutes
Resolved without any Rx
Pediatric SE
Clinical Course (cont.)
Pediatric SE
Dx
Pediatric SE
Rx
IV lorazepam
IV valproate
Transfer to Childrens
ICU observation
Uncomplicated course
Adolescent SE
Hx
Adolescent SE
Px
Adolescent SE
Clinical Course
Adolescent SE
Clinical Course (cont.)
Adolescent SE
Clinical Course (cont.)
Adolescent SE
Dx
New onset SE
Complex partial seizures with
generalized seizure / SE
Hx migraine headaches
Adolescent SE
Rx
Lorazepam to Rx the acute sz
2 mg IVP x 2
Juvenile Myoclonic Sz
Hx
Juvenile Myoclonic Sz
Px
Vitals OK
Neuro: slightly post-ictal
Exam otherwise normal
Patient has a 2nd seizure in the ED
Juvenile Myoclonic Sz
Dx
Juvenile myoclonic epilepsy
Related to sleep deprivation, alcohol
consumption
Occurs upon awakening
Responds best to valproate
Phenytoin may exacerbate sx
Edward Sloan, MD, MPH
Juvenile Myoclonic Sz
Rx
Conclusions
Clinical Pearls
Acute, repetitive spells = sz
Ongoing altered mental status =
complex partial SE
Treat acute szs with lorazepam
Valproate is the etiology-specific
ongoing Rx in many young people
Know the specific JME clinical setting
Edward Sloan, MD, MPH
Conclusions
Learning Points
Recommendations
Management Implications