Case Based Peds in your EDCase Based Peds in your ED

My kid is seizingMy kid is seizing My kid is vomitingMy kid is vomiting My kid is having trouble breathingMy kid is having trouble breathing My baby stopped breathingMy baby stopped breathing

20 cases over the next 90 minutes20 cases over the next 90 minutes Audience participation is Audience participation is requestedrequested

Case Based Peds in your EDCase Based Peds in your ED

My kid is seizingMy kid is seizing My kid is vomitingMy kid is vomiting My kid is having trouble breathingMy kid is having trouble breathing My baby stopped breathingMy baby stopped breathing

20 cases over the next 90 minutes20 cases over the next 90 minutes Audience participation is Audience participation is requiredrequired

Managing Seizures in Managing Seizures in Pediatric PatientsPediatric Patients

in your EDin your ED

Frank Overly, MDFrank Overly, MDAssistant Professor Emergency Medicine and Assistant Professor Emergency Medicine and

PediatricsPediatrics

Alpert Medical School of Brown UniversityAlpert Medical School of Brown University

OverviewOverview

Case basedCase based Presentation of illnessPresentation of illness

Important questions to askImportant questions to ask ManagementManagement Physical findingsPhysical findings Work upWork up SummarySummary

Pediatric SeizuresPediatric Seizures

Most common neurologic disorder in Most common neurologic disorder in childhoodchildhood

4-6% of all kids will have 1 seizure before 4-6% of all kids will have 1 seizure before 16y/o16y/o

5 year old female 5 year old female GTC seizureGTC seizure Started 15 minutes agoStarted 15 minutes ago

T-101, P-155, RR-40, BP-110/80, Ox Sat-89%T-101, P-155, RR-40, BP-110/80, Ox Sat-89%

What would you like to do? What would you like to do?

What history do you want to know?What history do you want to know?

Case One

Useful History for SeizureUseful History for Seizure Does s/he have a fever?Does s/he have a fever? Does s/he have a seizure disorder?Does s/he have a seizure disorder?

If yes, is s/he on anti-seizure meds?If yes, is s/he on anti-seizure meds? If yes, is s/he taking them, or any recent If yes, is s/he taking them, or any recent

changes?changes? Any trauma?Any trauma? Any medicines s/he had access to?Any medicines s/he had access to? How was s/he before the seizure started?How was s/he before the seizure started? Is s/he developmentally normal?Is s/he developmentally normal? Bottle or breast?Bottle or breast? Did you have a party last night?Did you have a party last night?

PMHx former 27 week’erPMHx former 27 week’er Has a known seizure disorderHas a known seizure disorder On phenobarbOn phenobarb Has a fever and is seizingHas a fever and is seizing

Case One

Oxygen, NPAOxygen, NPA

Ask for IV access and d-stickAsk for IV access and d-stick

Ask to draw up Benzo (or phenobarb)Ask to draw up Benzo (or phenobarb)

Getting startedGetting started

Case One

Seizure IV Medication Seizure IV Medication DosagesDosages

LorazepamLorazepam

DilantinDilantin PhenobarbitalPhenobarbital Valproic AcidValproic Acid

0.1mg/kg0.1mg/kg

20mg/kg20mg/kg20mg/kg20mg/kg

20mg/kg20mg/kg

I ain’t got no…I ain’t got no…IV access...IV access...

LorazepamLorazepam 0.1mg / kg IM0.1mg / kg IM Diazepam Diazepam 0.5mg / kg PR0.5mg / kg PR 0.1mg / kg IM0.1mg / kg IM MidazolamMidazolam 0.5mg / kg IM0.5mg / kg IM

0.2mg / kg Intranasal0.2mg / kg Intranasal 0.15mg / kg PR0.15mg / kg PR

FosphenytoinFosphenytoin 20 PE/ kg IM20 PE/ kg IM

Seizure StopsSeizure Stops

What would you like to know and do?What would you like to know and do?

Case One

Chem 7 Chem 7 WNLWNL CBC CBC WBC – 22K WBC – 22K

(60 seg, 30 lymph, 10 (60 seg, 30 lymph, 10 mono)mono)

H/H – 15/45H/H – 15/45

PLT – 600KPLT – 600K U/A U/A normalnormal

Phenobarb level -5 (therapeutic 15-40)Phenobarb level -5 (therapeutic 15-40)

Case One

16 month old female was sleeping in bed 16 month old female was sleeping in bed with parents when they heard a cry and then with parents when they heard a cry and then noticed she was stiff and arms jerking. She noticed she was stiff and arms jerking. She was seizing for 5 minutes.was seizing for 5 minutes.

Brought to ED Brought to ED

VS T-102, P-145, RR-25, BP-90/60, Ox Sat-VS T-102, P-145, RR-25, BP-90/60, Ox Sat-98%98%

Case Two

After antipyretic running around smilingAfter antipyretic running around smiling

VS T-98, P-80, RR-20, BP-85/60VS T-98, P-80, RR-20, BP-85/60

PE – normal examPE – normal exam

What do you want to do?What do you want to do?

What do you tell the family?What do you tell the family?

Case Two

Febrile SeizuresFebrile Seizures

SimpleSimple GeneralizedGeneralized Less than 15-20 minutesLess than 15-20 minutes One in 24 hour periodOne in 24 hour period

ComplexComplex Anything that is not simple Anything that is not simple

Febrile SeizuresFebrile Seizures

6 months to 6 years6 months to 6 years 2-5 % of kids have a febrile seizure2-5 % of kids have a febrile seizure 33% will have a second33% will have a second 10% will have 3 or more10% will have 3 or more No proven increase risk of epilepsy in No proven increase risk of epilepsy in

“normal” kids“normal” kids

Simple Febrile SeizuresSimple Febrile Seizures Work-upWork-up

Find source of fever and treat itFind source of fever and treat it

If you think they have meningitis tap themIf you think they have meningitis tap themLow threshold to tap kids less than 12 Low threshold to tap kids less than 12

monthsmonths

Complex Febrile SeizuresComplex Febrile Seizures Work-upWork-up

Find source of fever and treat itFind source of fever and treat it Work up for seizure Work up for seizure

Febrile SeizuresFebrile SeizuresAntipyretics (what do you tell parents?)Antipyretics (what do you tell parents?)

Worth giving, but no study shows you Worth giving, but no study shows you can prevent future febrile seizurescan prevent future febrile seizures

6 month old female, brought in by rescue. 6 month old female, brought in by rescue. Mother called and felt the child was having Mother called and felt the child was having trouble breathing. trouble breathing.

Seizing, GTC activitySeizing, GTC activity

T-95, P–180, RR–40, BP–80/50, Ox Sat–T-95, P–180, RR–40, BP–80/50, Ox Sat–95%95%

What would you like to know and do?What would you like to know and do?

Case Three

PEPE No sign of traumaNo sign of trauma Fontanelle flatFontanelle flat No rashesNo rashes Rhythmic jerking of arms bilaterallyRhythmic jerking of arms bilaterally Eyes rolled backEyes rolled back Not respondingNot responding

Case Three

Oxygen, NPA Oxygen, NPA Saturation 100% Saturation 100% IV access IV access nice work! nice work! D-stick D-stick 100 good to know Lorazepam 0.1mg/kg X 2 doses Lorazepam 0.1mg/kg X 2 doses thank thank

you!you!

Still seizing???Still seizing???

Case Three

Oxygen, NPA Oxygen, NPA Saturation 100% Saturation 100% IV access IV access nice work! nice work! D-stick D-stick 100 good to know Lorazepam 0.1mg/kg X 2 doses Lorazepam 0.1mg/kg X 2 doses thank thank

you!you!

Still seizing???Still seizing???

Case Three

Na – Na – 119119 K- 4K- 4 Cl – 100Cl – 100 CO2 – 23CO2 – 23 Bun – 15Bun – 15 Cr – 0.3Cr – 0.3 Glu - 120Glu - 120

Case ThreeLABS

If HyponatremicIf Hyponatremic

If less than 125mEq/l and seizingIf less than 125mEq/l and seizing

3%NS3%NS 3cc/kg3cc/kg

Repeat with the goal to get up to 125 mEq/l Repeat with the goal to get up to 125 mEq/l which should stop seizureswhich should stop seizures

Hypothermia(<36.5 or 97.7), bottle fed, seizingHypothermia(<36.5 or 97.7), bottle fed, seizing check Na+check Na+

4 month old brought in by mom, seizing. She 4 month old brought in by mom, seizing. She says she went to check on him and he was says she went to check on him and he was shaking all over. Tried to give him a bath shaking all over. Tried to give him a bath because she thought he was cold but still because she thought he was cold but still shaking.shaking.

T-99.1, P-170, RR-25, BP-110/80, Ox sat-89%T-99.1, P-170, RR-25, BP-110/80, Ox sat-89%

What physical findings would you look for?What physical findings would you look for?

Case Four

Physical (obviously complete exam including)Physical (obviously complete exam including) ““Is the baby seizing?”Is the baby seizing?” Signs of infectionSigns of infection

Fever or hypothermiaFever or hypothermia Signs of traumaSigns of trauma OrganomegalyOrganomegaly Dysmorphic featuresDysmorphic features

Big head, little head, VP shuntBig head, little head, VP shunt Skin findingsSkin findings

Physical Findings to Look ForPhysical Findings to Look For

NeurofibomatosisNeurofibomatosis

If you see these…..

Think about these….

Order one of these…..

Port-wine StainPort-wine StainSturge-WeberSturge-Weber

leptomeningeal angioma

Hyperpigmentation, virilizationHyperpigmentation, virilizationAddison’s, CAHAddison’s, CAH Hyponatemia, hyperkalemia, hypoglycemiaHyponatemia, hyperkalemia, hypoglycemia

What the ??????

Nice tan???

Ash Leaf Macules – Ash Leaf Macules – Tuberous SclerosisTuberous Sclerosis

PEPE Anterior fontanelle bulgingAnterior fontanelle bulging Pupils are minimally reactivePupils are minimally reactive CV – RRRCV – RRR Resp – CTA Bilat, but shallow breathsResp – CTA Bilat, but shallow breaths Abd – distendedAbd – distended Ext – bruising on the armsExt – bruising on the arms Neuro – eyes deviated to right, Neuro – eyes deviated to right,

increased tone, seizingincreased tone, seizing

Case Four

Case Four

Case Four

What do you want to do?

Airway (if not already intubated)Airway (if not already intubated) Fosphenytoin or phenobarbFosphenytoin or phenobarb Mannitol (is BP adequate?)Mannitol (is BP adequate?) Nearest pediatric neurosurgeonNearest pediatric neurosurgeon

Any other children at home?Any other children at home? Document the story well!!Document the story well!!

Case Four

7 year old was at home working on his 7 year old was at home working on his computer and parents heard a thump, computer and parents heard a thump, they ran upstairs and found him they ran upstairs and found him seizing. seizing.

Lasted 2 minutes, he was tired for 30 Lasted 2 minutes, he was tired for 30 minutes and now back to baselineminutes and now back to baseline

What would your work up be?What would your work up be?

Case Five

If If normal examnormal exam and and no significant PMHxno significant PMHx

Will need outpatient EEG, outpatient neurologyWill need outpatient EEG, outpatient neurology Possibly an MRI of brainPossibly an MRI of brain

No Head CT No Head CT (some say 1/1000 mortality for each pediatric head (some say 1/1000 mortality for each pediatric head

CT)CT)

No Blood workNo Blood work

Case Five

Who gets a scan?Who gets a scan?

Focal seizureFocal seizure Persistent seizurePersistent seizure Focal neurological deficitFocal neurological deficit VPSVPS Neurocutaneous disorderNeurocutaneous disorder Signs of increased ICPSigns of increased ICP History of traumaHistory of trauma ImmunocompromisedImmunocompromised Bleeding disorder (sickle cell, hyper or Bleeding disorder (sickle cell, hyper or

hypocoagulable)hypocoagulable)

Who gets labs?Who gets labs?

Bedside glucose:Bedside glucose: Think about it oftenThink about it often

Electrolytes for:Electrolytes for: Prolonged or persistent seizuresProlonged or persistent seizures Younger than 6 months oldYounger than 6 months old History of metabolic disorder, diabetes, History of metabolic disorder, diabetes,

dehydration, excess water intake, altered LOCdehydration, excess water intake, altered LOC

Who gets labs?Who gets labs?

Tox screen if altered LOCTox screen if altered LOC

CSF for:CSF for: neonatal seizuresneonatal seizures altered LOC, prolonged postictal periodaltered LOC, prolonged postictal period signs of meningitissigns of meningitis

Rescue arrives with a 2 year old seizing. Rescue arrives with a 2 year old seizing. Parents woke up and found the child in the living Parents woke up and found the child in the living room on the floor seizing. room on the floor seizing.

T-98, P-160, RR-40, BP-80/50, Ox Sat-92%T-98, P-160, RR-40, BP-80/50, Ox Sat-92%

There was a party the night beforeThere was a party the night before

You get one lab test what is it and why?You get one lab test what is it and why?

Case Six

the parents did not clean up the mixed the parents did not clean up the mixed drinks laying around the house.drinks laying around the house.

Case Six

Maybe Miller had a Miller!Maybe Miller had a Miller!

D-stick 35D-stick 35

Case Six

If HypoglycemicIf Hypoglycemic

Dextrose Dextrose (0.25-1 g/kg)(0.25-1 g/kg) D5NS D5NS 10cc/kg10cc/kg D10NSD10NS 5 cc/kg5 cc/kg 5050 D25NSD25NS 2cc/kg2cc/kg

Remember to start an infusionRemember to start an infusion

The Basics as always….The Basics as always…. AirwayAirway

Oxygen (non rebreather)Oxygen (non rebreather) NP airwayNP airway PositioningPositioning

Breathing Breathing remember cricoid pressure if BVMremember cricoid pressure if BVM

CirculationCirculation Fluids if needed (NS)Fluids if needed (NS)

D,D,D,D duhhhhhh…D,D,D,D duhhhhhh…Dextrose …..check d-stickDextrose …..check d-stick

AccessAccess Three attempts at IVThree attempts at IV

Consider other routesConsider other routes Think IM, PR, intranasalThink IM, PR, intranasal

IM LorazepamIM Lorazepam IM, PR, Intranasal MidazolamIM, PR, Intranasal Midazolam PR Diazapam (Diastat)PR Diazapam (Diastat)

Agree on a weight and ask for meds earlyAgree on a weight and ask for meds early Broslow? Other routine? Broslow? Other routine? Not the best time to be practicing Not the best time to be practicing

multiplicationmultiplication

Additional PearlsAdditional Pearls

Pyridoxine (Vit B6)Pyridoxine (Vit B6)

Consider for persistent seizures in patient Consider for persistent seizures in patient <1 yr<1 yr 50-100 mg IV50-100 mg IV

Consider in suspected Isoniazid toxicityConsider in suspected Isoniazid toxicity Initial dose 70mg/kgInitial dose 70mg/kg

FosphenytoinFosphenytoin

Nicer to veinsNicer to veins Can be infused rapidly with less Can be infused rapidly with less

hypotensionhypotension 20 Phenytoin equivalents/kg load20 Phenytoin equivalents/kg load

4 day old is brought into your ED for poor 4 day old is brought into your ED for poor feeding. You notice this……..feeding. You notice this……..

VS T-99, P-165, RR-35, BP-70/45, Ox Sat VS T-99, P-165, RR-35, BP-70/45, Ox Sat 99%99%

Case Seven

PEPE No sign of traumaNo sign of trauma No rashesNo rashes Well hydratedWell hydrated No dysmorphic featuresNo dysmorphic features Normal toneNormal tone Eyes deviated to the leftEyes deviated to the left Persistent lip smacking/sucking/chewingPersistent lip smacking/sucking/chewing

What would you like to do?What would you like to do?

Case Seven

Neonatal SeizuresNeonatal Seizures Rare to have GTC movementsRare to have GTC movements

Immature cortical developmentImmature cortical development Can be subtle focal findingsCan be subtle focal findings

Repetitive movementsRepetitive movementsEye blinkingEye blinkingEye deviationEye deviationChewingChewingLip smackingLip smackingBicyclingBicycling

Neonatal SeizuresNeonatal Seizures

Can be focal tonic or clonic seizuresCan be focal tonic or clonic seizures

Sustained posturing of one or more Sustained posturing of one or more extremitiesextremities

Possibly just rhythmic jerking of single Possibly just rhythmic jerking of single extremityextremity

Na – 140Na – 140 K - 4K - 4 Cl – 98Cl – 98 CO2 – 24CO2 – 24 Bun – 16Bun – 16 Cr – 0.4Cr – 0.4 Glu - 110Glu - 110

Ca – 7Ca – 7 Mg – 1.1Mg – 1.1 Phos - 2Phos - 2

Case SevenLABS

HypocalcemiaHypocalcemia

Serum calcium Serum calcium < 7-8 mg/dl< 7-8 mg/dl 10% CaGluconate10% CaGluconate 1-2 ml/kg slow IV 1-2 ml/kg slow IV

infusioninfusion 10% CaCl10% CaCl 0.2ml/kg slow IV 0.2ml/kg slow IV

infusioninfusion Continuous ECG monitoringContinuous ECG monitoring

Chest x-ray looking for thymusChest x-ray looking for thymus

No thymus, big heartNo thymus, big heart

DiGeorge Syndrome Microdeletion of chromosome 22Microdeletion of chromosome 22

Low set earsLow set earsHypertelorisHypertelorismmMicrognathiaMicrognathiaFish MouthFish Mouth