Morning Report: 11/29/2012

Thanks to Dr. Basile for today’s Morning Report!

Pediatric Seizures:

– Up to 6% of children have at least one seizure in their childhood

– Variety of causes: toxic, metabolic, infectious, vascular, trauma, etc.

Our role as Emergency Physicians: Stabilize the patient, stop ongoing seizures, identify the cause of the seizure, and determine appropriate disposition and follow up

Age based differential:

a) Neonates (1-28 days):

1) Have potential for the worst prognosis and usually represent underlying pathology

2) Even without fever, must presume to have CNS infection (Group B Strep, HSV, E. Coli, Listeria, Strep Pneumo, Neisseria Meningitides, H. Flu., and TORCH pathogens)

3) HSV is one of the most devastating neonatal infections and usually present in the second or third week but can occur anytime in the first 6 weeks

4) At risk for ICH, structural brain abnormalities, and metabolic disorders

5) Withdrawal from in-utero exposure to alcohol, benzos, and opiates

6) Prognosis is poor: mortality rate of 24-30% and 65-78% of those that survive have a mental deficit later in life

7) All cases require neuroimaging, LP, and empiric coverage with Ampicillin, Gent, and Acyclovir (or equivalent regimen)

b) Children 1-6 months:

1) Most challenging for emergency medicine docs

2) Remain at significant risk for CNS infection (trend toward adult causes of meningitis such as N. Meningitides, Strep Pneumo, and H. Flu); in children under 6 weeks, treat the same as neonates if concern for infection

3) High risk for electrolyte and metabolic abnormality such as hypoglycemia and hyponatremia

4) If afebrile, require electrolyte (including calcium and magnesium) and glucose testing

5) If febrile also require a full septic work up including LP

c) Children 6 months to 5 years:

1) CNS infection less likely and will occur with other signs/symptoms including headache, meningismus, AMS, and an ill-appearing child

2) Must assess for ingestion or trauma

3) Febrile seizure most common cause of seizure in this age

4) Routine lab work not recommended unless warranted by history or physical

d) Older children and adolescents: Differential resembles that of adults

Work up of first-time simple febrile seizure:

– Simple febrile seizure: age 6 months to 5 years, fever > 100.4, generalized, lasting less than 15 minutes, return to baseline mental status, no recurrence of seizure in 24 hour period, no indication of CNS infection, and no history of prior epilepsy

– These children should be evaluated for cause of fever, but no need for invasive investigations to rule out CNS pathology in a well appearing child with normal neuro exam

– In the past LP was considered mandatory in first time seizure in a child 6 months to 12 months, but recent evidence point against this and current guidelines state LP is an option in children deficient in H. Flu or Strep Pneumo vaccines or if unknown vaccine history

– Slight increase in developing epilepsy

Work up of complex febrile seizure:

– Complex febrile seizures: age 6 months to 5 years, fever, no history of epilepsy, no indication of CNS infection, plus any of the following: focal component, longer than 15 min, or more than one seizure in a 24 hour period

– Children who recover quickly, have no indication of CNS infection, no focal neuro deficit, and are well appearing can be discharged with outpatient follow up.

– A more conservative approach including labs, imaging, and LP is often done in these patients, but there is little evidence of benefit of such work up.

– CT and LP are NOT indicated if otherwise asymptomatic

– Have larger risk of developing non-febrile seizures in the future (5-9%)

Neuroimaging in ED for first time non febrile seizures:

– Neonates with seizure all require imaging

– Imaging is often recommended if: suspected increased ICP, focal seizure, focal neuro deficit, seizure after head trauma, ill-appearing patient, prolonged seizure, or HIV infection

– MRI is the study of choice

– CT scans in children with new-onset seizure even if focal appear to be of little use unless there is persistent AMS, persistent focal deficit, concern for hydrocephalus, or trauma

Status Epilepticus Algorithm:

– Many people argue that status should be defined as seizure lasting longer than 5 minutes

– 60% of patients who present in status fail to have seizures terminated by first line medications

– First line is benzodiazepine and if not effective in 3-5 minutes, the dose should be repeated

– Second line is fosphenytoin/phenytoin (which should be given with the second benzo dose)

– By the time you get to third line, you will likely have established or are in the process of establishing a definitive airway via RSI. Third line agents include Phenobarbital, Versed drip, Propofol, Valproic acid, Keppra, or Ketamine

References:

Drullinger K, Amieva-Wang NE. Pediatric seizures. Critical Decisions in Emergency Medicine. 2012; 26(11): 12-20.