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pediatric neurologic

emergencies
may 2002 core rounds

contents
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

case 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

case 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?

case 3
16

year old
known seizure disorder, on phenytoin
typical seizure presenting complaint
V/S N, neuro N, otherwise looks well
approach?

case 4
2

week old
parents - doesnt 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?

definitions
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

definitions
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

classification
generalized
LOC
tonic, clonic, tonic-clonic, myoclonic, atonic, absence

partial

focal onset

simple partial no LOC


complex partial LOC
partial secondarily generalized

unclassified

etiology
infectious
metabolic
traumatic
toxic
neoplastic
epileptic
other

differential diagnosis
syncope
breath

holding
sleep disorders (eg. narcolepsy)
paroxysmal movement disorder
tics,tremors

migraines
psychogenic

seizures

approach to febrile seizures


the 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

simple febrile seizure


<

15 mins
no focal features
no greater than 1 episode in 24h
neurologically and developmentally normal

complex febrile seizure


>15

min

febrile epilepticus >30min or recurrent without

regaining consciousness > 30min


focal
recurrence

within 24h

what do parents want to


know?
recurrence
risk recurrence 25-50%
risk recurrence after 2nd 50%
most recurrences within 6-12 mo

risk

(20% within same febrile illness)

of epilepsy

2-3% (baseline 1%)


increased in

family history of epilepsy


abnormal developmental status
complex febrile seizure

neonatal seizure
brief

and subtle

eye blinking
mouth/tongue movements
bicycling motion to limbs

typically

szs cant be provoked/consoled


autonomic changes
EEG less predictable

neonatal seizure
etiology
hypoxic-ischemic encephalopathy

Presents within first day

congenital CNS anomalies


intracranial hemorrhage
electrolyte abnormalities hypoglycemia and

hypocalcemia
infections
drug withdrawal
pyrodoxine deficiency

status 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%

SE treatment considerations
ABCs
brief

directed Hx and Px

glucose
antibiotics/antivirals
if meningitis/encephalitis considered

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

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

refractory 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

approach 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

approach to stable patient


physical

directed towards

systemic disease
infection
toxic exposure
focal neuro signs

laboratory
blood

glucose?
electrolytes?
magnesium, calcium?
anything

at all?
what about first time seizures? recurrent?

laboratory
yes

if

neonatal
abnormal mental status persistent
diabetics, renal disease
diuretic use
dehydration
malnourishment

laboratory
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?

lumbar 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

neuroimaging
WHO?

which patients?

WHAT?

CT vs. MRI

ultrasound in neonates

WHEN?

emergent vs. elective

ACEP 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

neuroimaging

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

emergent EEG?
not

generally available on emergent basis


but consider in..
persistent altered mental status (?non

convulsive status epilepticus)


paralyzed patients
pharmacologic coma

disposition
can

be discharged home if

single seizure
stable, returning to baseline neuro status
no underlying condition/cause requiring

treatment in hospital
arranged follow-up

EEG 1st 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 EEGs 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

idiopathic seizure
recurrence

risk stratification

normal EEG 25%


abN EEG 60%
2nd seizure 75%

neuroimaging
MRI
not

superior

emergently available

?defer

imaging until follow-up MRI


available in low risk patients?

treatment
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

in

neonatal - phenobarbital
generalized TC phenytoin, phenobarbital, carbamazepine, valproic acid,
primidone
absence ethosuximide, valproic acid
new anti-epileptics felbamate, gabapentin, lamotrigine, topiramate,
tiagabine, vigabatrine

consultation with neurologist

pediatric headache

case 5
14

year old
mothers 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?

classification
classify
acute

based on temporal pattern

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

acute recurrent headache


migraine
other
cluster headache typically >10 yo
sinusitis
vascular malformation

migraine - 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

migraine treatment
very

little supporting evidence for pharmacologic


treatment in children compared to adults
classes of medication
acetaminophen
NSAIDS
phenothiazines (dopamine antagonists)
dihydroergotamine
triptans

the 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, placebocontrolled, crossover study
Neurology 48:103-107, 1997
N = 88 age 4-16
relief at 2 hours
acetaminophen 54%
ibuprofen 68%

other 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

dihydroergotamine
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

phenothiazines
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

triptans
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

chronic progressive headache


least

common presentation

most

worrisome for increased ICP

pseudotumor cerebri
space occupying lesion

imaging indications? discuss


lack

of evidence to help

small studies lack power to guide decision

making
MRI

preferred in non-urgent indication

imaging 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 ?)