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Pediatric Neurologic Emergencies

Pediatric Neurologic Emergencies. Leybie Ang July 31 2008. Objectives. Febrile Seizures Status Epilepticus Encephalitis. FEBRILE SEIZURE. Case Presentation. 16 month old, former 38 weeker Previously healthy Brought in by EMS Seizure activity at home Lasting 1-2 minutes

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Pediatric Neurologic Emergencies

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  1. Pediatric Neurologic Emergencies Leybie Ang July 31 2008

  2. Objectives • Febrile Seizures • Status Epilepticus • Encephalitis

  3. FEBRILE SEIZURE

  4. Case Presentation • 16 month old, former 38 weeker • Previously healthy • Brought in by EMS • Seizure activity at home • Lasting 1-2 minutes • Arms and legs twitching • 3 days hx of URI symptoms

  5. Febrile Seizure – Definition • NIH definition • An event in infancy or childhood usually occurring between 3 month and 5 year of age, associated with fever but without evidence of intracranial infection or defined cause of seizure

  6. Febrile Seizure - Incidence • 2-5% in children < 5yo • Up to 15% • Majority between 12-18mo • One parent – 4.4x • Both parents – 20x • Sibling – 3.6 x • Second degree relative – 2.7x

  7. Simple Febrile Seizure • Most common • Seizure < 15 minutes • No focal features • Only once in 24hr time period

  8. Complex Febrile Seizure • Episodes lasting > 15 minutes • Focal features or postical paresis • > 1 episode in 24 hrs • Seizure in a series with total duration > 30minutes

  9. Risk Factors For Recurrence • Low fever at time of first sz (<40) • Young age (<12 month old) • Family hx of febrile sz • Short period of time between fever and sz (<24hr) • ?male

  10. Risk Factors For Developing Epilepsy • Family Hx of epilepsy • Complex features • Presence of early onset neurodevelopmental abnormalies

  11. Febrile Seizure - Immunization • Risk of febrile seizure increases • By 1.5 fold on day of DTP immunization • Risk now reduced if DTaP • Acellular pertussis instead of whole cell pertussis • By 3.0 fold with the peak occurring 1-2 weeks after MMR vaccination

  12. Differential Diagnosis • Shaking/Chills • Trauma • Toxins • Metabolic disorder • Meningitis/Encephalitis

  13. Febrile Seizure - Management • A • B • C

  14. Febrile Seizure - Management • Antipyretics • Sponging • Antiepileptic

  15. Febrile Seizures – Antipyretics • Uhari et al J peds 1995 126:991 180 kids RDBPC (plac + plac, plac + acet, diaz + acet, diaz + plac) no difference in recurrence x2yrs • Schnaiderman et al Eur J Peds 1993 152:747 104 kids RCT acet q4h scheduled or prn, no difference • Van Stuijvenberg et al Peds 1998 102:1 230 kids RDBPC ibuprofen to plac no diff X1yr

  16. Febrile Seizure - Antipyretics • Meremikwa et al Cochrane Database 2002 • Systematic review of 12 trials acetaminophen vs placebo +/-sponging • Insufficient evidence

  17. Febrile Seizure - Diazepam • Dose given when: • when child is febrile • before start seizing • or as soon as start seizing • Oral dosage given at time of fever – 44% reduction in the risk of febrile seizure per person-year with diazepam

  18. Febrile Seizure - Phenobarbital • Effective in preventing recurrence of simple febrile seizure • Daily therapy reduced the rate of subsequent febrile seizure from 25% to 5% • Adverse effect : • hyperactivity, hypersensitivity reaction (SJS), loss of cognitive function

  19. Febrile Seizure – Valproic Acid • As effective as phenobarbital in preventing recurrent simple febrile seizure • More effective than placebo • Side effect : • Fatal hepatotoxicity (esp <3yo at greatest risk)

  20. Febrile Seizure - Prevention Committee on Quality Improvement Subcommittee on Febrile Seizure of the AAP 1999 • “Based on the risk and benefits of effective therapies, neither continuous nor intermittent anticonvulsant therapy is recommended for children with one or more simple febrile seizures. AAP recognises that recurrent episodes of febrile seizures can create anxiety in some parents and their children and as such appropriate educational and emotional support should be provided”

  21. Question #1 • In the emergency department, you are talking with the parents of a 17 month old boy who was evaluated for a first generalised seizure that lasted 7 minutes and followed by a fever 102.9 F (39.4 C). Other than OM, findings on the physical examination were normal, and the child was discharged home. The child is developmentally normal. Upon examination, the child now appears well.

  22. Of the following, your MOST likely statement to the parents is that • A. antipyretic agents are effective in preventing future febrile seizures • B. CT head is preferred to MRI brain for evaluation of this child • C. EEG is not indicated • D. The chance of another febrile sz is ~50% • E. The child has a 5% chance of developing epilepsy

  23. STATUS EPILEPTICUS

  24. Status Epilepticus - Introduction • EFA • Two or more sequential seizures without full recovery of consciousness between seizures, or more than 30 minutes of continuous seizure activity • 10-58 per 100,000 per year for children 1 to 19 year old • More common in in children with epilepsy 9-27%

  25. Status Epilepticus - Etiology • 26% acute CNS insult • Bleed • Trauma • Infection • 20% underlying seizure disorder • Sudden discontinuation of meds • Drug interaction • Fever • 53% unknown

  26. Status Epilepticus

  27. Status Epilepticus – Blood Culture • Should blood culture be routinely done in children in SE? • Six Class III studies, total 357 children, BC positive in 2.5% • Insufficient data to support or refute in children whether blood cultures should be done routine basis in children whom there is no clinical suspicious for infection

  28. Status Epilepticus – Lumbar Puncture • Should LP be routinely done in children with SE? • Class III studies – out of 1,859 children 12.8% has documented CNS infection • Insufficient data to support or refute in children whether lumbar puncture should be done routine basis in children whom there is no clinical suspicious for infection

  29. Status Epilepticus – AED Levels • Should AED levels be routinely obtained in children taking AED who develop SE? • Class II data showed that low AED levels in 32% of children on AEDs • AED levels should be considered when a child with epilepsy on AED prophylaxis develops SE

  30. Status Epilepticus – Toxicology Testing • Should toxicology testing be routinely ordered in children with SE? • Class III studies showed that a diagnosis of ingestion in 3.6% • Toxicology testing maybe considered in children with SE, when no apparent etiology is immediately identified. • Specific serum toxicology level is required

  31. Status Epilepticus - EEG • Should an EEG be routinely performed in the evaluation of a child with SE? • Class III studies reported that abnormal brain activity on 43.1% of EEG done on SE • EEG may be considered in a child with new onset SE

  32. Status Epilepticus – Imaging • Neuroimaging may be considered for the evaluation of the child with SE if there are clinical indications or if the etiology is appropriately stabilised and the seizure activity controlled

  33. Imaging - CT vs. MRI • MRI useful for: • More detailed view of brain anatomy • Better screen for CNS malformations and dysplastic lesions, temporal lobe (esp. hippocampus) • CT useful for: • Larger neoplasms, old infarctions, major malformative processes • Assessment of the critically ill child

  34. Status Epilepticus - Managemnet • A • B • C

  35. SE treatment • 1st 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

  36. SE treatment • 2nd 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) • 3rd line agents • Phenobarbital 20mg/kg @ 100mg/min • Repeat prn 5-10mg/kg • Maximum 40 mg/kg or 1 gram

  37. Refractory SE treatment • Consider midazolam • 0.2 mg/kg bolus • 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

  38. Status Epilepticus - Complications • Hypoxia • Impaired ventilation • Increased secretions • Increased O2 consumption • Impaired O2 delivery • Metabolic and respiratory acidosis • Brain injury • Hypoxia and hypoperfusion • MR, behaviour changes, neuro deficits

  39. Status Epilepticus - Complications • Morbidity • < 1yo - 30% • > 3yo – 6% • Mortality • 3%

  40. Question #2 • A 8 month old girl is brought into the emergency department in status epilepticus. She has had diarrhea for the past 4 days. The infant had received bottled water for the past 3 days of her illness and cola for the past 24hr.

  41. Of the following, the MOST likely cause of her status epilepticus is • A. Hypocalcemia • B. Hypoglycemia • C. Hypokalemia • D. Hypomagnesemia • E. Hyponatremia

  42. ENCEPHALITIS

  43. Case Presentation • 16 yo old female presents with fever, headache, neck stiffness, swallowing difficulties and altered mental status • Symptoms have worsened over past 2 days. • Roommate noted a change in behaviour for the past week • 2 weeks ago had a bad URTI- missed 2 days of school

  44. Encephalitis • Defined as acute CNS dysfunction with radiographic or laboratory evidence of brain inflammation • 1. Primary Encephalitis • cause bloodstream infection, then enter the CNS • 2. Post- or Parainfectious • not caused by direct CNS infection • consequence of the host’s immune response

  45. Encephalitis • HSV - typically infects neurons in the temporal lobe • Rabies - predominantly affects the pons, medulla, cerebellum, and hippocampus • Japanese encephalitis virus affects the brainstem and basal ganglia.

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