Acute Management of Seizure Disorders in Children

What is a seizure?

• Seizure: paroxysmal event characterized by a change in behavior of the patient; it is caused by abnormal and excessive activity of a group of cortical neurons.

• Epilepsy: occurrence of two or more unprovoked seizures

Etiology of Seizures

• Acute Symptomatic

• Remote Symtomatic

• Idiopathic

Classification of seizures

Generalized• loss of consciousness

• whole brain at onset

Partial• no loss of consciousness

• focal onset

Convulsive• tonic clonic

• tonic

• clonic

Nonconvulsive • absence

• atypical absence

• myoclonic

• atonic

Complex Partial• change in level of consciousness

Simple Partial• no change in consciousness

Partial Seizure evolving to secondary generalization

Epilepsy Syndromes

• Triad of seizure type or types, age and EEG findings

• Different medications for different syndromes!!

• Very different prognoses for different syndromes

Was it a seizure?Nonepileptic events

• Syncope- vasovagal, cardiogenic• Sandifer syndrome• Breath holding spell• Migraine• Tics• Psychogenic• Sleep myoclonus• Paroxysmal dystonia

Management of Seizures in the ED

• The first unprovoked seizure

• Status Epilepticus– Convulsive– Nonconvulsive

• Febrile Seizures

• Neonatal Seizures

• Managing the known epilepsy patient

Managing a First Unprovoked Seizure in ChildhoodHistory

• Describe seizure very carefully– Length of seizure- do not take parents estimate of time lapsed at face value!– What was child doing when the seizure occurred?– What did seizure look like at its onset? During the seizure? – What happened after the seizure?– What does the child remember?

• Possible precipitants of seizure– Head trauma? Possible ingestion? New medication or supplement?Fever? Dehydration? Rash? Change in

mental status? Recent travel?

• Ask about other seizure types!– Absence: does your child eve stop an stare and not respond– Myoclonus

• Review of systems– Headaches, double vision, weakness, numbness, vomiting, etc– General ROS

• PMH

• Developmental History

Managing a First Unprovoked Seizure in ChildhoodPhysical

• General exam– Including: vital signs, signs of head trauma, signs of meningitis and sepsis, rash, etc

• Directed general exam– Head circumference– Dysmorphic features– Neurocutaneous stigmata– Extremity abnormality– Organomegaly

• Neurologic Exam– Mental status, including assessment of developmental level– Cranial Nerves– M otor– Reflexes– Tone– Gait– Cerebellar

Managing a First Unprovoked Seizure in ChildhoodLaboratory Evaluation

Hertz D et al: Practice Parameter: Evaluating a first nonfebrile seizure in children. Neurology 2000; 55:616.

• The below recommendations are for the child who has retrrned to baseline

• “There is sufficient Class I evidence… to provide a recommendation

…that an EEG be obtained in all children in whom a nonfebrile seizure has been diagnosed, to predict the risk of recurrence and to classify the seizure type and epilepsy syndrome. “

• “The decision to perform other studies, including LP, laboratory tests, and neuroimaging, for the purpose of determining the cause of the seizure and detecting potentially treatable abnormalities, will depend on the age of the patient and the specific clinical circumstances. Children of different ages may require different management strategies”

Managing a First Unprovoked Seizure in ChildhoodLaboratory Evaluation

• Blood– CBC, CMP

• Urine– Utox- consider

– Urinalysis

• Neuroimaging– CT

• If focal onset seizure, Todd’s paralysis, focal exam, possibility of trauma

• If onset of seizure not witnessed

• If follow up not assured

– MRI • May be done as outpatient if felt to be warranted

• EEG– outpatient

Treatment of the child with a first unprovoked seizureHirtz d et al: Practice parameter: Treatment of the child with a first unprovoked seizureNeurology 2003;60:166.

• “Treatment with AED is not indicated for the prevention of the development of epilepsy (Level B).”

• “Treatment with AED may be considered in circumstances where the benefits of reducing the risk of a second seizure outweigh the risks of pharmacologic and psychosocial side effects (Level B).”

• In general, first unprovoked seizures are not treated with long term anticonvulsants

Risk factors for seizure recurrence after first unprovoked

seizure• Todd’s paralysis

• Seizure in sleep

• Developmental Delay

• Neurologic abnormality

• Abnormal neuroimaging

• Abnormal EEG

• Positive family history for epilepsy

Status Epilepticus in Children

Definition of Status Epilepticus

• 30 minute duration of seizures (or two or more sequential seizures without full recovery of consciousness between seizures)

• For practical purposes, start treatment earlier

Complications of Status Epilepticus

• Hypoxemia• Acidemia• Glucose alterations• Blood pressure disturbances• Increased intracranial pressure• Morbidity

– Neurologic sequelae– Focal motor deficits– Mental retardation– Behavioral disorders– Chronic epilepsy– Acute and chronic MRI changes

• Mortality– 3-4%

Status Epilepticus

• Common in children, particularly in children less than 2 years old

• Particularly common in children with epilepsy (9-27% over time have at least one episode of status)

Classification of Status Epilepticus

• Focal– Simple focal– Complex focal

• Generalized– Convulsive– Nonconvulsive

• Psychogenic

Etiology of Status Epilepticus

• Acute symptomatic

• Remote symptomatic

• Progressive Encephalopathy

• Febrile

• Cryptogenic

Etiology of Status Epilepticus

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Differential Diagnosis of Status Epilepticus

• Movement Disorder– Drug induced dystonic reaction– Sandifers syndrome

• Breathholding spell

• Spasm– Secondary to increased ICP

• Psychogenic seizure

Evaluation and Treatment of Convulsive Status Epilepticus

Copyright ©2000 BMJ Publishing Group Ltd.

The Status Epilepticus Working Party, et al. Arch Dis Child 2000;83:415-419

No Caption Found

Management of Status Epilepticus in ChildrenInitial Approach

Status Epilepticus Working Party, 2000• Initial assessment

– A, B, Cs– Rapid neurologic examination– Brief history – Give high flow oxygen

• Measure rapid blood glucose– More to avoid glucose infusion than the uncommon hypoglycemic seizures

• Confirm epileptic seizure– Not all events are epileptic!!!!

• Laboratory Studies– Glucose, electrolytes, calcium, magnesium– ABG– CBC– Serum anticonvulsant drug levels (if indicated)– Toxicology screening

Brief, directed history

• Has the child ever had a seizure before?• History of trauma? Fever? Ingestion?• What medications (including nonprescription) does the

child take?• Was the child his usual self prior to this event?• Any medical problems?• Any neurologic/developmental problems?• If child with known epilepsy

– Has the child missed dosage of medication• If so, consider loading with that medication

– Be aware of paradoxical side effects of ACDS• Phenytoin and carbamazepine toxicity may precipitate SE

Rapid Neurologic Evaluation• Observation

– What is the patient doing• What are the movements? Which extremities involved?• Stiff or floppy?• What are eyes doing? Head?• Is patient at all responsive?

– To verbal stimuli– Noxious stimuli– Withdrawal approprate?

• Cranial Nerves– Pupil reactivity, extraocular movements

• Motor/Sensory: – What parts of body are moving? What parts withdraw to nailbed

pressure

Treatment of Convulsive Status Epilepticus in ChildrenStatus Epilepticus Working Party, 2000

ImmediatelyABCs

High flow oxygen measure blood glucoseConfirm epileptic seizure

IV access No IV access

Lorazepam Diazepam

Lorazepam Paraldehyde

Fosphenytoin orPhenytoin

ANDParaldehyde

Insert interosseous line

Rapid sequence induction of anesthesia with thiopentone

After 10 minutes

After 10 minutes

After 20 minutes

After 10 minutes

After 10 minutes

Management of SE in childrenWith no IV access

• Diazepam 0.5 mg/kg PR– Diastat– IV diazepam, inserted per rectum through butterfly

(needle cut off!)– Repeat dose if no response in 5 minutes

• Midazolam 0.1-0.2 mg/kg intramuscularly

• If seizures continue another 10 minutes:– Insert interosseous line

Management of SE in Children with IV access

Overview1. Lorazepam 0.1 mg/kg IV over 30-60 seconds1. If seizures continue another 10 minutes, repeat lorazepam dosage

2. If seizure continues:1. Fosphenytoin18 PE/kg over 7 minutes or 2. Phenytoin 18-20mg/kg over 20 minutes (general rule of thumb: for each

1mg/kg phenytoin or 1PE/kg fosphenytoin expect rise in level by approximately 1)

3. If already on phenytoin load with phenobarbital 20mg/kg over 10 minutes

3. If seizure continues another 20 minutes:1. Phenobarbital 20 mg/kg IV (2 mg/kg/min)2. May repeat 10mg/kg every thirty minutes

4. Confirm this is truly an epileptic seizure and continue to look for underlying treatable cause

5. Call for back up from anesthetist or intensive care specialist

Step 1: Lorazepam

• Lorazepam 0.1 mg/kg IV over 30-60 seconds– If seizures continue another 5-10 minutes, repeat

lorazepam dosage

• Lorazepam vs. Diazepam – Lorazepam

• Equally or more effective than diazepam• Longer duration of action (6-12 hours vs. <1 hour)• Less respiratory depression than diazepam• Not available rectally

– Diazepam• Highly effective in rapidly terminating seizures• However, redistribution into adipose tissue limits anticonvulsant effect to less

than 20 minutes• Available in rectal gel, which can be given outside the ED

Step 2: Load Fosphenytoin (or Phenytoin)

Phenytoin vs. FosphenytoinPhenytoin

• Can be diluted in NS only!• Maximum concentration of

10mg per ml• Infusion rate < 1 mg/kg/min

(Therefore 18 mg/kg is infused over no less than 18 minutes)

• Risk of hypotension and cardiac arrythmia

• Monitor heartrate BP and EKG• Extravasation reaction, purple

glove syndrome

Fosphenytoin• Pro drug: converted into

phenytoin• Can be diluted in commonly

used diluents• Can infuse 3 times more rapidly

than phenytoin (ie, over 7-8 minutes)

• Decreased risk hypertension and arrhythmia

• Decreased risk extravasation reactions (pH of 8)

• Dosed in phenytoin equivalents (PE) which can be confusing.

Step 2: Fosphenytoin (or phenytoin)

• Fosphenytoin18-20 PE/kg over 7 minutes or Phenytoin 18-20mg/kg over 20 minutes

• If already on phenytoin, load with phenobarbital 20mg/kg over 10 minutes

• General rule of thumb: for each 1 mg/kg phenytoin (or 1PE/kg fosphenytoin) expect level to rise by 1)

Step 3: Phenobarbital

• If seizure continues another 20 minutes:• Phenobarbital 20 mg/kg IV (2 mg/kg/min)• May repeat 10mg/kg every thirty minutes

• Confirm this is truly an epileptic seizure and continue to look for underlying treatable cause

Phenobarbital– Long acting anticonvulsant; very long half

life (90 hours)– Respiratory depression and sedation

potentiated by benzodiazepine

Steps 4 and 5

• If seizures continue:– Call for backup from anesthetist or intensive

care specialist– Rapid sequence induction of anesthesia

• Use only short acting neuromuscular paralytics (or can mask signs of seizure)

• Isoflurane and desflurane

– Please note: this is rarely done in the US

Refractory SE• Definition: continued seizures after 2 or 3 antiepileptic

drugs have failed

• Will usually need EEG monitoring at this point; typically titrate to burst suppression; intubation and intravascular monitoring in ICU setting

Refractory SE

• Inhalational anesthetics

• Midazolam

• Pentobarbital

• Propofol

• Valproic acid

• Keppra

• IV pyridoxine

Midazolam

– Short half life– IV, IM, intranasal, PO, buccal or rectal– Can be given as continuous IV infusion for

refractory SE– Midazolam infusion

• 0.1-0.3 mg/kg IV followed by 1mcg/kg/min IV infusion.• Increase every 15 minutes as necessary• Maximum 8-10 mcg/kg/min

Pentobarbital

• Short acting; used for refractory SE• Significant side effects: respiratory depression, hypotension,

myocardial depression, reduced cardiac output, pulmonary edema, ileus

• Intubation and intravascular monitoring required• 5-10 mg/kg intravenously/IO loading dose followed by 0.5-3

mg/kg/h• Thiopental

– Used for refractory SE– Active metabolites which can accumulate– Possibly higher adverse reactions than pentobarbital

Propofol

– Intravenous anesthetic– Small number of studies show effectiveness– Risk of hypotension, apnea, metabolic acidosis

and bradycardia– Contraindicated in child on ketogenic diet– 1-2 mg/kg load, followed by 2-10 mg/kg/hr

infusion

Valproic acid

• Not yet approved for initial treatment of SE

• Appears effective and safe

• Dosage– 20-40 mg/kg IV (diluted 1:1 with normal saline or

5% dextrose in water) over 5-10 minutes; may repeat in 10-15 minutes

– Follow with IV infusion of 5 mg/kg/hr

Keppra

• 1500 to 4000mg IV

• A few small studies have showed promise

Summary: Refractory SE

• Inhalational anesthetics• Pentobarbital

• Short acting; Significant side effects: respiratory depression, hypotension, myocardial depression, reduced cardiac output, pulmonary edema, ileus; Intubation and intravascualr monitoring usually required

• Thiopental• Active metabolites which can accumulate; Possibly higher adverse reactions

than pentobarbital• Propofol

• Intravenous anesthetic; Risk of hypotension, apnea and bradycardia• Contraindicated in child on ketogenic diet

• Midazolam• Short half life; IV, IM, intranasal, PO, buccal or rectal• 0.1-0.3 mg/kg IV followed by 1mcg/kg/min IV infusion; increase every 15

minutes as necessary; maximum 8-10 mcg/kg/min• Valproic acid

• 20-40 mg/kg IV (diluted 1:1with normal saline or 5% dextrose in water) over 5-10 minutes; may repeat in 10-15 minutes. Follow with IV infusion of 5 mg/kg/hr

• Keppra• Consider IV pyridoxine

Diagnostic Assessment Searching for causes of acute symptomatic seizures• Metabolic

– Hypoglycemia– Hypocalcemia– Hyponatremia– Inborn Error of Metabolism

• Febrile• Trauma• Infectious

– Meningitis– Sepsis

• Stroke– Ischemic– Hemorrhagic

• Tumor• Brain Malformation• Hypertensive• Etc.

Diagnostic assessmentRiveillo et al: Practice Parameter: Diagnostic assessment of the child with status epilepticus (an

evidence-based review) Neurology 2006;67:1542-1550

• Basic bloods: CBC, electrolytes, calcium, glucose are assumed will be obtained

• Blood cultures– Insufficient data to support or refute whether blood cultures should be done

on a routine basis on whom there is no clinical suspicion of infection– Corollary: if there is clinical suspicion of infection, obtain one

• LP– Insufficient data to support or refute whether CSF cultures should be done on

a routine basis on whom there is no clinical suspicion of CNS infection– Corollary: if there is clinical suspicion of CNS infection, obtain LP.

• If mental status remains clouded after seizure is stopped and the clinical suspicion is low for meningitis, can wait for 1-2 hours to see if patient returns to baseline. If patient has not returned to baseline at that point, will need to do LP

• In an infant, definitely LP• Measuring AED levels

– AED levels should be considered when a child with epilepsy on AED prophylaxis develops SE

– Translation: send the levels

Diagnostic assessmentRiveillo et al: Practice Parameter: Diagnostic assessment of the child with status epilepticus (an

evidence-based review) Neurology 2006;67:1542-1550• Toxicology testing– Toxicology testing may be considered in children with SE, when no apparent etiology is

immediately identified• Metabolic and genetic testing

– Studies for inborn errors of metabolism should be considered when the initial evaluation reveals no etiology, especially if there is a preceding history suggestive of a metabolic disorder such as:

• Unexplained neonatal encephalopathy• Neurologic deterioration during an acute illness• Unexplained developmental delay• Unexplained acidosis or coma (bear in mind status itself caused acidosis)• Unusual odors in urine• Need to eat frequently to prevent lethargy

– Insufficient date to support or refute whether genetic testing should be done routinely in children with SE

– Initial metabolic tests to consider if indicated as above• Amino acids• Urine organic acids• Ammonia• ABG• VLCFA• Lactic acid/pyruvate

Diagnostic assessmentRiveillo et al: Practice Parameter: Diagnostic assessment of the child with status epilepticus (an

evidence-based review) Neurology 2006;67:1542-1550

• EEG– An EEG may be considered in a child presenting with new onset SE as it

may determine whether there are focal or generalized abnormalities that may influence diagnostic and treatment decisions

– An EEG may be considered in a child presenting with SE if the diagnosis of pseudostatus epilepticus is suspected

– Translation: Get an EEG• Neuroimaging

– Neuroimaging may be considered for the evaluation of the child with SE if there are clinical indications or if the etiology is unknown (if etiology is known, eg has a history of epilepsy, usually do not need neuroimaging acutely)

– If neuroimaging is done, it should only be done after the child is appropriately stabilized and the seizure activity stopped

– In acute period, CT scan (rather than MRI) is safer as patient can be closely monitored. However, MRI provides superior detail

Diagnostic Assessment• CBC, electrolytes, calcium, glucose• LP indicated if there is clinical suspicion of CNS infection.

– in a young infant, have low threshold for LP– If patient has not returned to baseline mental status after a period of time (I usually use 4-6 hour cut off),

then will need LP• Measure AED levels, if appropriate• Consider toxicology testing• Consider urgent imaging (CT scan)• Get an EEG (non emergent)• Consider MRI• Metabolic and genetic testing

– Consider studies for inborn errors of metabolism if the initial evaluation reveals no etiology– Possibilities

• Amino acids• Urine organic acids• Ammonia• ABG• VLCFA• Lactic acid/pyruvate

Disposition

• Patient gets admitted for observation for 24 hours

• Or, longer, depending on underlying cause

Home treatments

• Diastat– Dosage: 0.5 mg/kg, round up– DIASTAT AcuDial

• 10mg delivery system with a 4.4 cm tip(delivers doses of 5, 7.5 and 10 mg)

• 20 mg delivery system with a 6.0 cm tip(delivers doses of 10, 12.5 and 20 mg)

• Twin Pack of 2 pre-filled configurations (pharmacist locks in proper dosage)

• Intranasal midazolam

Nonconvulsive Status Epilepticus

• Morbidity and mortality significantly lower

• May be difficult to diagnose- may need EEG (this is one of the few needs for urgent EEG)

• Treatment– Benzodiazepene– Valproic Acid

Neonatal Seizures

Neonatal Seizures Etiology

• Hypoxic ischemic encephalopathy• CNS infection• Metabolic Distubances

– Hypoglycemia– Hypocalcemia– Hypomagnesemia– Pyridoxine dependency

• Intracranial Hemorrhage• Cerebral Infarction• Chromosomal abnormalities• Congenital Brain abnormalities• Drug withdrawal or intoxication• Inborn errors of metabolism

Neonatal Seizures

Etiology Time of Onset

Hypoxic ischemic encephalopathy 12-24 hour

Drug withdrawal 24-72 hour

Hypocalcemia (nutritional) 3-7 days

Aminoaciduria/organic aciduria 3-7 days

Diagnostic Assessment of Neonatal Seizures

• Metabolic testing (screening)– Blood glucose– Calcium– Ammonia– Lactate– pH– electrolytes

• LP– Cells– Protein/glucose– Cultures– Herpes PCR– Lactate/pyruvate– Aminoacids

• Neuroimaging– Head ultrasound– Head CT– Brain MRI

• EEG

Neonatal Status EpilepticusTreatment

• Phenobarbital– Usually used first– Prolonged half life—100 hours after day 5-7; therefore watch for toxicity– 20 mg/kg IV (up to 40 mg); repeat 10/kg every 15-30 minutes times two

• Phenytoin/Fosphenytoin– 20 mg/kg (over 30-45 minutes)– Half-life 100 hours– Nonlinear kinetics; redistribution, variable rate hepatic metabolism

require individuallization of maintenance dosing• Benzodiazepine

– Diazepam• 0.25mg/kg IV bolus or 0.5 mg/kg PR

– Lorazepam• 0.05 mg/kg IV over2-5 minutes

• Midazolam infusion

Pyridoxine

• . Pyridoxine-dependent seizures– Intractable seizures that respond both clinically and

electrographically to pyridoxine– Neonatal presentation is typical, but late onset seizures

do occur– Diagnosis:

• 100 mg of pyridoxine intravenously while monitoring the EEG.

• If a clinical response is not demonstrated, the dose should be repeated up to a maximum total of 500 mg.

• If patient has pyridoxine-dependent seizures, clinical and electrograhic seizures generally cease over several minutes.

Benign febrile seizure

• Definition – 6 months to 6 years– Fever– Neurologically normal before and after seizure– Generalized seizure– Lasts less than fifteen minutes– No other obvious cause of seizure

• AAP recommendations– The evaluation should be directed towards the diagnosis of the cause of the fever. – Lumbar Puncture

• Over 18 months: not necessary as long as there is no clinical suspicion of meningitis.• 12 months and 18 months of age : consider• Under 12 months of age: strongly consider, as signs of meningitis can be subtle in this

age group. – EEG, blood studies and neuroimaging are generally not required.

• Long term anticonvulsants generally not used• Diastat for home use indicated if there is a history of prolonged febrile seizure

or cluster of seizures (ie, not benign febrile seizures)

The child with epilepsy who has a seizure

History The child with known epilepsy who has a seizure

• Acute Seizure History– Describe seizure, length of seizure– Is today’s seizure typical of the patient’s usual seizures?– Has the patient missed any dosages of medications?– Has the patient been sick? Febrile? Vomiting? – Started a new medication? Supplements? Foods? – Travel? Trauma?

• Epilepsy History– What kind of seizure(s)/epilepsy syndrome does the patient have?– Why (if known) does the patient have epilepsy? (e.g., neonatal stroke, encephalitis, etc)– How frequent are the patient’s seizures in general? – What anticonvulsant is the patient on?

• What is the dosage? Do not just check bottle; ask mom what she is giving the patient• Calculate all anticonvulsants into mg/kg/day• What and when was the most recent level?

– If patients seizures are poorly controlled:• When was the most recent dosage change?• What medications has he been on in the past for seizures?

• PMH– Any significant past medical history? What medications is the patient on?

Evaluation The child with known epilepsy who has a seizure

• Examination– is patient at baseline?

• If pertinent, send level of anticonvulsant – For the “old line” medications: phenobarbital,

dilantin, tegretol, valproic acid, ethosuximide– Can not send levels for the newer ACDs

Management of the epileptic child with breakthrough seizure

• If level low– Missed doses- give extra dose and leave maintenance the

same

– If no missed doses and daily dosage is within the typical range for maintenance, then give bolus (usually in the range of one extra dose) and raise daily dosage by 10%

• If level high– Is this peak or trough level?

– Is high level of ACD potentially a cause of seizure – Eg, tegretol

What not to do

• If child is at baseline, do NOT do neuroimaging, EEGs, blood cultures,etc!