|




 
` My kid is seizing
` My kid is vomiting

` My kid is having trouble breathing

` My baby stopped breathing

` 20 cases over the next 90 minutes

` Audience participation is 

 |



 
` My kid is seizing
` My kid is vomiting

` My kid is having trouble breathing

` My baby stopped breathing

` 20 cases over the next 90 minutes

` Audience participation is 
  

  


 

Ôrank Overly, MD
Assistant Professor Emergency Medicine and
Pediatrics
Alpert Medical School of Brown University
 ë  
` |ase based
` Presentation of illness
` Important questions to ask
` Management
` Physical findings
` Work up
` Summary
  

` Most common neurologic disorder in
childhood

` 4-6% of all kids will have 1 seizure before

16y/o
 |

` V year old female
` GT| seizure
` Started 1V minutes ago

` T-101, P-
P-1VV, RR-
RR-40, BP
BP--110/80, Ox Sat-
Sat-89%

` What would you like to do?

` What history do you want to know?

 G


 

` Does s/he have a fever?
` Does s/he have a seizure disorder?
` If yes, is s/he on anti-
anti-seizure meds?
` If yes, is s/he taking them, or any recent
changes?
` Any trauma?
` Any medicines s/he had access to?
` How was s/he before the seizure started?
` Is s/he developmentally normal?
` Bottle or breast?
` Did you have a party last night?
 |


PMHx former 27 week¶er

` Has a known seizure disorder
` On phenobarb

` Has a fever and is seizing

 |


m
 
` Oxygen, NPA

` Ask for IV access and d-

d-stick

` Ask to draw up Benzo (or phenobarb)

  





` Dorazepam 0.1mg/kg

` Dilantin 20mg/kg
` Phenobarbital 20mg/kg
` Valproic Acid 20mg/kg
  


 



` Dorazepam 0.1mg / kg IM
` Diazepam 0.Vmg / kg PR
0.1mg / kg IM
` Midazolam 0.Vmg / kg IM
0.2mg / kg Intranasal
0.1Vmg / kg PR

` Ôosphenytoin 20 PE/ kg IM
 |


` Seizure Stops

` What would you like to know and do?

 |

` |hem 7 WND
` |B| WB| ± 22K
(60 seg, 30 lymph, 10 mono)
H/H ± 1V/4V
PDT ± 600K
` U/A normal

` 
   !" #$! %&'
 |


` 16 month old female was sleeping in bed

with parents when they heard a cry and then
noticed she was stiff and arms jerking. She
was seizing for V minutes.

` Brought to ED

` VS T-
T-102, P-
P-14V, RR-
RR-2V, BP-
BP-90/60, Ox Sat-
Sat-
98%
 |

` After antipyretic running around smiling

VS T-
T-98, P-
P-80, RR-
RR-20, BP
BP--8V/60

PE ± normal exam

What do you want to do?

What do you tell the family?

 Ô

` Simple
` Generalized

` Dess than 1V-

1V-20 minutes
` One in 24 hour period

` |omplex
` Anything that is not simple
 Ô

` 6 months to 6 years
` 2-V % of kids have a febrile seizure

` 33% will have a second

` 10% will have 3 or more

` No proven increase risk of epilepsy in

³normal´ kids
 (#Ô

` Work
Work--up
` Ôind source of fever and treat it

` Ifyou think they have meningitis tap them

`Dow threshold to tap kids less than 12
months
 |
(#)Ô

` Work
Work--up
` Ôindsource of fever and treat it
` Work up for seizure
 Ô

Antipyretics (what do you tell parents?)
` Worthgiving, but no study shows you
can prevent future febrile seizures
 |


` 6 month old female, brought in by rescue.
Mother called and felt the child was having
trouble breathing.

` Seizing, GT| activity

` T-9V, P±
P±180, RR±
RR±40, BP
BP±
±80/V0, Ox Sat±
Sat±
9V%

` What would you like to know and do?

 |


` PE
` No sign of trauma
` Ôontanelle flat

` No rashes

` Rhythmic jerking of arms bilaterally

` Eyes rolled back

` Not responding
 |



` Oxygen, NPA Saturation 100%

` IV access nice work!

` D-stick 100 good to know

` Dorazepam 0.1mg/kg X 2 doses thank
you!

` Still seizing???
 |



` Oxygen, NPA Saturation 100%

` IV access nice work!

` D-stick 100 good to know

` Dorazepam 0.1mg/kg X 2 doses thank
you!

` Still seizing???
 |


D


` Na ± èè
` K- 4

` |l ± 100

` |O2 ± 23

` Bun ± 1V

` |r ± 0.3

` Glu - 120
  #
 (
` If less than 12VmEq/l and seizing

` 3%NS 3cc/kg

` Repeatwith the goal to get up to 12V mEq/l

which should stop seizures

 #
( "*+,!
-..'/
/

01 2
 |


` 4 month old brought in by mom, seizing. She

says she went to check on him and he was
shaking all over. Tried to give him a bath
because she thought he was cold but still
shaking.

` T-99.1, P-
P-170, RR-
RR-2V, BP-
BP-110/80, Ox sat-
sat-89%

` What physical findings would you look for?


 Ô

3

0Ô

Physical (obviously complete exam including)
` ³Is the baby seizing?´

` Signs of infection
` Ôever or hypothermia
` Signs of trauma
` Organomegaly

` Dysmorphic features

` Big head, little head, VP shunt

` Skin findings
 Neurofibomatosis
   


^  

 




  

Port--wine Stain
Port
`Sturge
Sturge--Weber

î
  î 

Hyperpigmentation, virilization
`Addison¶s, |AH
` Hyponatemia, hyperkalemia, hypoglycemia

  u  

Ash Deaf Macules ±
Tuberous Sclerosis
 |


` PE
` Anterior fontanelle bulging

` Pupils are minimally reactive

` |V ± RRR

` Resp ± |TA Bilat, but shallow breaths

` Abd ± distended

` Ext ± bruising on the arms

` Neuro ± eyes deviated to right,

increased tone, seizing
|


 |


u



 |


` Airway (if not already intubated)

` Ôosphenytoin or phenobarb

` Mannitol (is BP adequate?)

` Nearest pediatric neurosurgeon

` Any other children at home?

` Document the story well!!
 |

`7 year old was at home working on
his computer and parents heard a
thump, they ran upstairs and found
him seizing.

` Dasted 2 minutes, he was tired for 30

minutes and now back to baseline

` What would your work up be?

 |


` If 
( ) ( and 

 )

` Will need outpatient EEG, outpatient neurology

` Possibly an MRI of brain

` No Head |T
` (some say 1/1000 mortality for each pediatric
head |T)

` No Blood work
 u

 
 4
` Ôocal seizure
` Persistent seizure
` Ôocal neurological deficit
` VPS
` Neurocutaneous disorder
` Signs of increased I|P
` History of trauma
` Immunocompromised
` Bleeding disorder (sickle cell, hyper or
hypocoagulable)
 u

 
4
Bedside glucose:
` Think about it often

Electrolytes for:
` Prolonged or persistent seizures
` Younger than 6 months old
` History of metabolic disorder, diabetes,
dehydration, excess water intake, altered
DO|
 u

 
4
Tox screen if altered DO|

|SÔ for:
` neonatal seizures
` altered DO|, prolonged postictal period

` signs of meningitis
 |


` Rescue arrives with a 2 year old seizing.

Parents woke up and found the child in the living
room on the floor seizing.

` T-98, P-
P-160, RR-
RR-40, BP
BP--80/V0, Ox Sat
Sat--92%

` There was a party the night before

` You get one lab test what is it and why?

 |


` the parents did not clean up the mixed

drinks laying around the house.
   5
 |


`D-stick 3V
  #
 (
` Dextrose (0.2V-
(0.2V-1 g/kg)
` DVNS 10cc/kg
` D10NS V cc/kg !&
` D2VNS 2cc/kg

6((

  


 


 

` Airway
` Oxygen (non rebreather)
` NP airway
` Positioning

` Breathing
` remember cricoid pressure if BVM
` |irculation
` Ôluids if needed (NS)
` D,D,D,D duhhhhhh«
` Dextrose «..check d-
d-stick
 


` Three attempts at IV
` |onsider other routes
` Think IM, PR, intranasal
` IM Dorazepam
` IM, PR, Intranasal Midazolam
` PR Diazapam (Diastat)

` Agree on a weight and ask for meds early

` Broslow? Other routine?
` Not the best time to be practicing
multiplication

  

  
)",'
` |onsider for persistent seizures in patient
<1 yr
` V0
V0--100 mg IV

` |onsider in suspected Isoniazid toxicity

` Initial dose 70mg/kg
 Ô

# 

` Nicer to veins
` |an be infused rapidly with less
hypotension
` 20 Phenytoin equivalents/kg load
 |


`4 day old is brought into your ED for poor

feeding. You notice this««..

` VS T-
T-99, P-
P-16V, RR-
RR-3V, BP-
BP-70/4V, Ox Sat
99%
 |

` PE
` No sign of trauma
` No rashes
` Well hydrated
` No dysmorphic features
` Normal tone
` Eyes deviated to the left
` Persistent lip smacking/sucking/chewing

` What would you like to do?

 1
  

` Rare to have GT| movements
` Immature cortical development
` |an be subtle focal findings
` Repetitivemovements
`Eye blinking
`Eye deviation
`|hewing
`Dip smacking
`Bicycling
 1
  

´ |an be focal tonic or clonic seizures

` Sustained posturing of one or more

extremities

` Possibly just rhythmic jerking of single

extremity
 |

D


` Na ± 140 `| 6 .
6
`K - 4 ` Mg ± 1.1
` |l ± 98 ` Phos - 2
` |O2 ± 24

` Bun ± 16

` |r ± 0.4

` Glu - 110
  #
 (
` Serum calcium <77--8 mg/dl
` 10% |aGluconate1
|aGluconate 1-2 ml/kg slow IV
infusion
` 10% |a|l 0.2ml/kg slow IV
infusion
` |ontinuous E|G monitoring

` |hest x-
x-ray looking for thymus
1
 (
/ 
m
 
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