Pediatric neurologic emergency may 2002.ppt

Pediatric neurologic emergency may 2002.ppt

1. pediatric neurologic pediatric neurologic
emergenciesemergencies
may 2002 core rounds

2. contentscontents
seizures
–approaches to
febrile seizure
new onset non-febrile seizure
established seizure disorder with recurrence
neonatal seizures
status epilepticus
–investigation, treatment, disposition
headache
–discussion (as little evidence to support)
migraine treatment
imaging indications

3. case 1case 1
2 year old
parents “shaking episode” lasting “10 mins”
EMS called - child no longer shaking
V/S - BP 105/60 HR 100 RR 18 Sat N T39

approach?
–well looking child

first event

multiple events
–sick looking child

4. case 2case 2
8 year old
parents describe good history for tonic-clonic activity
lasting 2 mins
1st event
post event confusion - improving
in ED - V/S N, N sensorium, N neuro exam
otherwise healthy, no meds, no allergies
approach?

5. case 3case 3
16 year old
known seizure disorder, on phenytoin
typical seizure presenting complaint
V/S N, neuro N, otherwise looks well
approach?

6. case 4case 4
2 week old
parents - “doesn’t look right”, “mouth opening and
closing”
one episode lasting 1 minute
child not interested in feeding, sleepy
V/S - BP 90/50 HR 130 RR 38 sat N T 37.8
otherwise normal exam
approach?

7. definitionsdefinitions
febrile seizure – NIH defn - event of
infancy/childhood, typically between age
3mo and 5yrs, with no evidence intracranial
infection or defined cause
epilepsy - two or more seizures not
provoked by a specific event such as fever,
trauma, infection, or chemical change

8. definitionsdefinitions
neonatal seizure – in first 28 days of life
(typically first few days)
status epilepticus
–seizure lasting >30 mins

NB rosen 5-10 mins
–sequential seizures without regain LOC >30min

9. classificationclassification
generalized
–LOC
–tonic, clonic, tonic-clonic, myoclonic, atonic, absence
partial – focal onset
–simple partial – no LOC
–complex partial – LOC
–partial secondarily generalized
unclassified

10. etiologyetiology
infectious
metabolic
traumatic
toxic
neoplastic
epileptic
other

11. differential diagnosisdifferential diagnosis
syncope
breath holding
sleep disorders (eg. narcolepsy)
paroxysmal movement disorder
–tics,tremors
migraines
psychogenic seizures

12. approach to febrile seizuresapproach to febrile seizures
the numbersthe numbers
epidemiology
–age 3mo – 5yrs
–peak age 9-20 mo
–2-5% children will have before age 5
–25-40% will have family history
–80 – 97% simple
–3 - 20% complex

13. simple febrile seizuresimple febrile seizure
< 15 mins
no focal features
no greater than 1 episode in 24h
neurologically and developmentally normal

14. complex febrile seizurecomplex febrile seizure
>15 min
–febrile epilepticus >30min or recurrent without
regaining consciousness > 30min
focal
recurrence within 24h

15. what do parents want to what do parents want to
know?know?
recurrence
–risk recurrence 25-50%
–risk recurrence after 2
nd
– 50%
–most recurrences within 6-12 mo
(20% within same febrile illness)
risk of epilepsy
–2-3% (baseline 1%)
–increased in
family history of epilepsy
abnormal developmental status
complex febrile seizure

16. neonatal seizureneonatal seizure
brief and subtle
–eye blinking
–mouth/tongue movements
–“bicycling” motion to limbs
typically sz’s can’t be provoked/consoled
autonomic changes
EEG less predictable

17. neonatal seizureneonatal seizure
etiology
–hypoxic-ischemic encephalopathy
Presents within first day
–congenital CNS anomalies
–intracranial hemorrhage
–electrolyte abnormalities – hypoglycemia and
hypocalcemia
–infections
–drug withdrawal
–pyrodoxine deficiency

18. status epilepticusstatus epilepticus
definition
–deizure lasting >30 mins

NB Rosen 5-10 mins
–sequential seizures without regain LOC >30min
mortality in pediatric status epilepticus 4%
morbidity may be as high as 30%

19. SE treatment considerationsSE treatment considerations
ABC’s
brief directed Hx and Px
glucose
antibiotics/antivirals
–if meningitis/encephalitis considered

20. SE treatmentSE treatment
1
st
line anticonvulsants
–IV

lorazepam 0.1mg/kg

diazepam 0.2 mg/kg

midazolam 0.2 mg/kg
–rectal diazepam

2-5 yrs – 0.5 mg/kg

6-11 yrs – 0.3 mg/kg

>12 yrs – 0.2 mg/kg
–IM, intranasal, buccal midazolam

21. SE treatmentSE treatment
2
nd
line agents
–phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min)
–fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150
mg/min)
3
rd
line agents
–phenobarbital 20mg/kg @ 100mg/min
–repeat prn 5-10mg/kg
–maximum 40 mg/kg or 1 gram

22. refractory SE treatmentrefractory SE treatment
consider midazolam
–0.2 mg/kg bolus
–then 1-10 mcg/kg/min infusion
induce barbiturate coma
–pentobarbital 5-15 mg/kg @ 25 mg/min
–then 1-5 mg/kg/hour
others
–valproic acid
–paraldehyde, chloral hydrate
–propofol, inhalational anesthesia, paralysis
–lidocaine

23. approach – stable post szapproach – stable post sz
history
–pre-seizure
what was child doing when attack occurred
precipitants – fever, trauma, poisoning, drug/med use
aura
–deizure
what movements – incl. eyes
how long
LOC?
consequences – resp distress, incontinence, injury
–post seizure
Post-ictal

24. approach to stable patientapproach to stable patient
physical directed towards
–systemic disease
–infection
–toxic exposure
–focal neuro signs

25. laboratorylaboratory
blood glucose?
electrolytes?
magnesium, calcium?
anything at all?
what about first time seizures? recurrent?

26. laboratorylaboratory
yes if…
–neonatal
–abnormal mental status persistent
–diabetics, renal disease
–diuretic use
–dehydration
–malnourishment

27. laboratorylaboratory
septic work-up (CBC, BC, urine C+S, CXR, LP)
–as indicated
sick child
< 12 - 18 mo
therapeutic drug levels
other
–ABG
–toxicologic screen
–TORCH, ammonia, amino acids in neonate
–CPK, lactate, prolactin – ?confirm seizure?

28. lumbar puncturelumbar puncture
patients at greatest risk for meningitis
–under 18 months of age
–seizure in the ED
–focal or prolonged seizure
–seen a physician within the past 48 hours
other indications
–concern about follow-up
–prior treatment with antibiotics
The American Academy of Pediatrics
“strongly consider” in infants under 12 months of age with a first
febrile seizure

29. neuroimagingneuroimaging
WHO? which patients?
WHAT? CT vs. MRI
–ultrasound in neonates
WHEN? emergent vs. elective

30. ACEP guidelines - >6 yoACEP guidelines - >6 yo
consensus indication for non-contrast CT
first time seizure patients
–if suspect structural lesion
–partial onset seizure
–age > 40
–no other identified cause
recurrent seizure patients
–change in pattern
–prolonged post-ictal period
–worsening mental status

31. neuroimagingneuroimaging
predictors of abnormal findings of computed tomography of the head in
pediatric patients presenting with seizures

Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23
–retrospective case series
–predicts CT scan results normal if
no underlying high-risk condition
–malignancy, NCT, recent CHI, or recent CSF shunt revision
older than 6 months
sustained a seizure of 15 minutes or less
no new-onset focal neurologic deficit
–not prospectively validated

32. emergent EEG?emergent EEG?
not generally available on emergent basis
but consider in..
–persistent altered mental status (?non
convulsive status epilepticus)
–paralyzed patients
–pharmacologic coma

33. dispositiondisposition
can be discharged home if
–single seizure
–stable, returning to baseline neuro status
–no underlying condition/cause requiring
treatment in hospital
–arranged follow-up

34. EEG – 1EEG – 1
stst
non-febrile seizure non-febrile seizure
follow-up EEG
–within 24h

Lancet 1998;352:1007-11

improved pick-up 51% vs 34%

? how soon do we get ours ?
–inter-ictal EEG’s often normal

neuro may do sleep deprivation study (provocation)
–absence epilepsy and infantile spasms are invariably
associated with an abnormal EEG
–spike and wave 3HZ

35. idiopathic seizureidiopathic seizure
recurrence risk stratification
–normal EEG – 25%
–abN EEG – 60%
–2
nd
seizure – 75%

36. neuroimagingneuroimaging
MRI superior
not emergently available
?defer imaging until follow-up MRI
available in low risk patients?

37. treatmenttreatment
correct underlying pathology, if any
antipyretics ineffective in febrile seizure
anti-epileptic choice often trial and error

no anti-epileptic 100% effective
febrile seizure – diazepam, phenobarbital, valproic acid
–Currently AAP does not recommend

neonatal - phenobarbital
generalized TC – phenytoin, phenobarbital, carbamazepine, valproic acid,
primidone
absence – ethosuximide, valproic acid
new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate,
tiagabine, vigabatrine
in consultation with neurologist

38. pediatric headachepediatric headache

39. case 5case 5
14 year old
mother’s chief complaint - “having headaches all the
time, getting worse, this is not normal!!” etc. etc……..
V/S N
looks in discomfort but otherwise well
approach?
–treatment
–imaging?

40. classificationclassification
classify based on temporal pattern
acute headaches
–any febrile illness, sinus/dental infection, intracranial
infection/bleed (AVM,SAH,trauma)
acute recurrent
chronic progressive
chronic non-progressive
–tension, psychogenic, post-traumatic, ocular refractive
error

41. acute recurrent headacheacute recurrent headache
migraine
other
–cluster headache – typically >10 yo
–sinusitis
–vascular malformation

42. migraine - terminologymigraine - terminology
classic migraine
–biphasic
neuro aura
headache, N/V, anorexia, photophobia
–either unilateral (older) / bilateral(younger) or both
common migraine
–malaise, dizziness, N/V, feels and looks sick
–unilateral/bilateral
migraine equivalent/”complicated migraine”
–transient neuro deficits
–+/- headache
migraine variants
–Cyclic N/V, abdo pain
–BPV

43. migraine treatmentmigraine treatment
very little supporting evidence for pharmacologic
treatment in children compared to adults
classes of medication
–acetaminophen
–NSAIDS
–phenothiazines (dopamine antagonists)
–dihydroergotamine
–triptans

44. the simple stuffthe simple stuff
acetaminophen 15 mg/kg PO 30mg/kg PR
ibuprofen 10 mg/kg PO
Hamalainen ML Ibuprofen or acetaminophen for the acute treatment
of migraine in children: A double-blind, randomized, placebo-
controlled, crossover study
Neurology 48:103-107, 1997
–N = 88 age 4-16
–relief at 2 hours
acetaminophen 54%
ibuprofen 68%

45. other NSAIDSother NSAIDS
naproxen 5-7 mg/kg PO
–no pediatric evidence
ketorolac IV 0.5 mg/kg (max 30mg dose)
–not studied in pediatric migraine
–not approved <16 yo
–Houck CS – Safety of intravenous ketorolac in children and cost savings with a unit
dosing system. J Pediatr - 01-Aug-1996; 129(2): 292-6

1747 children

0.2% hypersensitivity

0.1% renal complications (in patients with renal disease)

0.05% gi bleed

46. dihydroergotaminedihydroergotamine
not approved
?dose – 0.1 – 0.5 mg IV
not studied in emergency population
Linder SL – Treatment of childhood migraine with dihydroergotamine
mesylate Headache - 1994 Nov-Dec; 34(10): 578-80
–N = 30
–inpatient protocol
–IV DHE and PO metoclopramide – average 5 doses!
–80% response

47. phenothiazinesphenothiazines
again no studies
metoclopramide 1-2 mg/kg IV (max 10mg)
prochloperazine 0.1 – 0.15 mg/kg IV/IM/PO/PR
(max 10mg)
children may be more susceptible to EPS
–? pre-treat with benadryl

48. triptanstriptans
mostly studied in adolescent groups
sumitriptan subcutaneous 0.06mg/kg
–Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50 consecutive
patients with acute migraine in a pediatric neurology office practice. Headache 36:419–
422, 1996
–N = 50 age 6-18
–78% effective at 2 hours
–6% recurrence
sumitriptan intranasal
–long term treatment studies done
–no emergent studies
triptans PO
–studies plagued by high placebo response

49. chronic progressive headachechronic progressive headache
least common presentation
most worrisome for increased ICP
–pseudotumor cerebri
–space occupying lesion

50. imaging indications? discussimaging indications? discuss
lack of evidence to help
–small studies lack power to guide decision
making
MRI preferred in non-urgent indication

51. imaging indications? discussimaging indications? discuss
classically based on historical and physical
–sudden severe headache
–rapid increase over days - weeks
–chronic progressive
–suggestive of increased ICP
severe nocturnal headache (wakes or upon waking), changes in pain with
position, coughing
–following head trauma
–persistent neuro findings
? include migraine equivalents ?
–growth abnormality
–age (? <3 ?)