Pediatric Seizure and Status Epilepticus Management in the Emergency Setting.

Pediatric Seizure and Status Epilepticus

Managementin the

Emergency Setting

Edward P. Sloan, MD, MPH

Associate Professor & Research Development Director

Dept of Emergency Medicine

University of Illinois College of Medicine

Chicago, IL

Attending Physician Emergency Medicine

University of Illinois Hospital

Our Lady of the Resurrection

Medical Center

Edward Sloan, MD, MPH

Pediatric Seizures & SEClinical Case • A 13 year old female presents with a frontal HA and prior

migraines that are relieved with ibuprofen• She had some AMS in the AM, with unusual motor

activity (restless, thrashing on bed)• She had no other systemic sx, recent illness, or head

trauma• She presented with normal vital signs and normal

neurologic exam• What should the emergency physician do?• What is the expected outcome of this patient?


OverviewGlobal Objectives• Learn more about pediatric seizures

• Focus on peds sz etiologies

• Increase awareness of Rx options

• Enhance our ED management

• Improve patient care & outcomes

• Maximize MD & patient satisfaction


OverviewSession Objectives

• Review main peds sz types, etiologies

• Briefly discuss Rx based on sz type

• Discuss relevant ED peds sz cases

• Summarize what Rx options exist

• Discuss rational treatment decisions


OverviewPediatric Sz Epidemiology

• Common EMS & ED problem

• Szs are up to 6% of EMS encounters

• Up to 1% of all ED visits are peds sz

–Peds febrile: 1 in 125 visits (0.8%)

–Peds afebrile: 1 in 500 visits (0.2%)


OverviewPediatric Sz Epidemiology• 2-5% have a febrile seizure

• 1% have an afebrile sz by age 14

• Highest afebrile sz rate before age 3

• 0.4-0.8% of children dvlp epilepsy

• SE most common before age 1


OverviewPediatric SE Epidemiology• Mean age 3.2 yrs, median age 1 year

• 61% by age 3

• Etiology age dependent–25% is febrile SE

–Before age 1, 75% due to acute insult

–Epilepsy, fever, CNS infection common


Pediatric Sz EtiologiesMeningitis

• Altered mental status universal

• Seizures in 23% of meningitis cases

• Complex & GTC seizures common

• Simple seizures rarely seen

• HIB vaccine makes this etiology rare


Pediatric Sz EtiologiesHyponatremia

• Causes long duration szs and SE

• Infants < 6 months old, no clear etiol

• Too much water in formula

• Hypothermia (Temp < 36.5 degrees)


Pediatric Sz EtiologiesCocaine Toxicity

• Consider in new onset seizures

• Crack cocaine rocks ingested

• Especially when no other etiology

• Common in urban EDs


Pediatric SeizuresSeizure Outcome

• Immature CNS, myelinization–More prone to seizures

–More resistant to consequences

• Continuous seizures less toxic

• SE carries a low mortality (3-6%)


Pediatric SeizuresSE Outcome

• Based on CNS status prior to SE

• Normal CNS, 64% remain intact

• Mortality related to two factors:–Acute neurologic insult

–Chronic CNS condition


Pediatric SeizuresSeizure Type Classification• Generalized – Involves both cerebral hemispheres– Convulsive: tonic-clonic seizures– Non-convulsive: absence seizures

• Partial– Involves one cerebral hemisphere– Simple: no impaired consciousness– Complex: impaired consciousness


Seizure ClassificationGeneralized Seizures• Convulsive seizures– Tonic sz: sustained contractions– Clonic sz: rhythmic flexor spasms– Tonic-clonic sz: combined mvmts

• Non-convulsive– Simple absence: impaired consciousness– Complex absence: brief motor mvmts


Seizure ClassificationPartial Seizures• Simple seizures (no LOC)– Focal motor (Jacksonian)– Sensory or somatosensory– Autonomic– Psychic

• Complex (impaired consciousness)– Involves some cognitive, affective sx– Temporal lobe, psychomotor seizures


Pediatric SeizuresOther Generalized Sz Types

• Neonatal seizures

• Benign childhood epilepsy (Rolandic)

• Infantile spasms (West syndrome)

• Lennox-Gastaut syndrome

• Atonic seizures

• Febrile seizures


Pediatric SeizuresStatus Epilepticus Types• Convulsive SE : tonic-clonic sz• Non-convulsive SE: no tonic-clonic sz – Absence SE– Complex partial SE

• Subtle SE: prolonged convulsive SE– Worst prognosis, mortality > 30%– Persistent coma, focal motor mvmts only


Specific Seizure Types Generalized Tonic-Clonic Sz

• Seizure described as a convulsion

• May occur primarily or secondarily

• May be preceded by prodrome or aura

• Tonic, then clonic phase

• Tongue biting, urinary incontinence

• Last for minutes, then post-ictal


Specific Seizure Types Absence Seizure• Petit mal epilepsy

• Brief, limited motor activity

• Sudden interruption of consciousness

• Slight clonic mvmts, myoclonic jerks

• Automatisms also can be seen

• Last about 10 sec, not post-ictal


Specific Seizure Types Partial Seizure• Focal motor sz (Jacksonian, frontal)

• Focus and/or lesion in cerebrum

• Sz clearly related to a lesion

• Sz type related to site of sz focus

• CT scan is useful

• Simple partial sz pts have no AMS


Specific Seizure Types Complex Partial Seizure• Psychomotor, temporal lobe epilepsy

• Often a history of febrile seizures

• Complex aura, altered behavior

• Automatisms: lip smacking, chewing

• Not complete LOC, instead confused

• May secondarily generalize


Specific Seizure Types Neonatal Seizure• Occur in first 28 days of life

• Most occur shortly after birth

• Subtle sz: lip smack, eye mvmt, apnea

• Perinatal asphyxia, metabolic abn

• Hypoglycemia, hypocalcemia

• CNS infection, hemorrhage, lesion


Specific Seizure Types Benign Childhood Epilepsy

• Rolandic epilepsy

• Onset between 3 and 13 years of age

• Often occurs upon awakening

• Facial mvmts, grimacing, vocalizations

• EEG diagnosis


Specific Seizure Types Infantile Spasms• West syndrome

• Occurs up to one year

• May be symptomatic or idiopathic

• Sudden tonic movements of the head, trunk, extremities

• Must do full work-up, incl metabolic

• Caution, AED hepatotoxicity a risk


Specific Seizure Types Lennox-Gastaut Syndrome

• Onset from 1-8 years

• Peaks at 3-5 years

• Multiple seizure types

• GTC, tonic, absence, atonic szs

• ED Hx: exac of known sz disorder


Specific Seizure Types Atonic Seizures• Astatic or akinetic seizures• Sudden loss of motor tone• Child falls to the floor• May have myoclonic jerks • No clear generalized seizure• No etiology of apparent syncopal episode


Specific Seizure Types Febrile Seizures• Age: 6 months to 5 years

• Related to rapid rise in temperature

• Brief, self-limited generalized sz

• Complex: Focal, > 10-15 min, flurry

• 25% recurrence, esp if in child < 1 yr old

• Risk of epilepsy not significantly greater


Specific Seizure Types Juvenile Myoclonic Epilepsy• Common in teens, young adults

• Etiology of generalized TC seizures

• History of staring spells

• History of AM clumsiness, myoclonus

• Sleep deprivation, EtOH precipitants

• Phenytoin: worse myoclonus, absence sz


Specific SE Types Generalized Convulsive SE• Seizure lasting greater than 5-10 min

• Refractory to initial benzo therapy

• Flurry of seizures and coma

• CNS injury likely after 30-40 minutes

• Glutamate, cell death, tissue necrosis

• Injury even if systemic sx controlled


Specific SE Types Non-convulsive SE• No generalized tonic-clonic sz – Absence SE– Complex partial SE

• No frank coma

• More common in children

• Not always due to co-morbidity

• Mortality ?? not as high as in GCSE


Specific SE Types Subtle SE

• Late manifestation of GCSE, frank coma

• No longer with tonic-clonic mvmts

• Still actively seizing (electrical SE)

• Usu in older patients

• Marked co-morbidity (encephalopathic)

• Highest SE mortality


Seizure Therapy Generalized Seizure Protocol• Benzodiazepines– PR diazepam, IM midazolam, IV lorazepam

• Phenytoins– Fosphenytoin can be given IV or IM

• Phenobarbital or valproate – Less sedation with valproate

• Propofol or midazolam infusions– EEG monitoring, BP support key


Seizure Therapy Ongoing Therapies• Absence: Ethosuximide, valproate• Atonic: Valproate, clonazepam,

ethosuximide• Myoclonic: Valproate, clonazepam• Partial: Carbamazepine,

phenytoin, valproate• Generalized: Carbamazepine,

phenytoin, phenobarb, primidone, valproate


Case PresentationsED Pediatric Seizure Cases

• Pediatric complex partial SE

• New onset SE in an adolescent

• New onset sz in a college student


Pediatric SE: Pediatric Complex Partial SE

• How do we Dx complex partial SE?

• What is the optimal Rx protocol?

• Why?


Pediatric SEHx• 7 year old male

• Seizure-like activity?

• Patient with staring spells

• Some headache and shaking movement, esp of hands

• Frontal headache, vomiting


Pediatric SEHx (con’t)• Seen at 2130, 2230 sign-out

• AMS, r/o seizure disorder

• “Once all of the labs are back, he should be OK to go home…”


Pediatric SEPx• 98.7 98/60 72 20

• Well hydrated

• CV, lung exams normal

• Neuro exam intact


Pediatric SEClinical Course• 0220 “episode”

• Tachycardia, BP OK, airway OK

• Confused, staring off into space

• Episode lasted < 5 minutes

• Resolved without any Rx


Pediatric SEClinical Course (con’t)

• Three more episodes over 40’

• Similar autonomic symptoms

• Some non-purposeful ext mvmts

• Diaphoresis, urinary incontinence

• Remained somnolent between episodes


Pediatric SEDx• Repetitive episodes with AMS

• Autonomic symptoms noted

• Non-purposeful mvmts noted

• Rule out complex partial status epilepticus (CPSE)


Pediatric SERx• IV lorazepam

• IV valproate

• Transfer to Children’s

• ICU observation

• Uncomplicated course


Adolescent SE: New Onset AMS/Spells

• What is the AMS?

• Is it a seizure?

• How should we Rx new onset szs?

• What is the role of the ED EEG?

• When should it be ordered?


Adolescent SEHx• 13 year old female

• Frontal HA and prior migraines

• HA relieved with ibuprofen

• AMS in AM, with ?? motor activity

• Restless at home, thrashing on bed

• No other systemic sx or recent illness


Adolescent SEPx• Vitals OK, afebrile

• Alert, O x 3, NAD

• Head/Neck OK

• Chest/cor/abd OK

• Neuro: No focal deficit. MS OK


Adolescent SEQuestion # 1

•What diagnostic tests are indicated at this point?



•Did the patient have a seizure? •Does it influence Dx, Rx?



•Does the patient require admission for observation for possible new onset seizures?


Adolescent SEClinical Course• Labs, tox screen neg

• CT negative

• Neuro consult: EEG and then D/C

• Dx: AMS, r/o Seizure; migraine HA

• While EEG applied, pt with AMS

• Agitation, thrashing on cart



• Is this repeat spell a seizure? •What type?



•Does this AMS and motor activity require Rx? •What Rx?



•Does the patient now require admission for observation for possible new onset seizures?


Adolescent SEClinical Course (con’t)

• During EEG, pt with R face focal sz• Leftward gaze noted• Seizure then generalized• Meds were given• Seizure terminated



•What med is to be used for seizure control / SE termination?



•What med is to be used once SE is terminated?•Why?



•How should the meds be given?

•Why?


Adolescent SEClinical Course (con’t)

• SE terminated with Rx

• Pt stabilized, still somnulent

• ALS transfer team to Children’s

• Pt with resolving AMS at time of D/C


Adolescent SEDx

• New onset SE

• Complex partial seizures with generalized seizure / SE

• Hx migraine headaches


Adolescent SERx• Lorazepam to Rx the acute sz–2mg IVP x 2

• Valproate for ongoing protection–25 mg/kg load administered

– Infused over 20 minutes

• PRN meds during transfer






Juvenile Myoclonic Sz: College Student, New Onset Sz

• What is the likely etiology?

• What is JME?

• What are the long-term implications?

• How to RX once the sz terminated?


Juvenile Myoclonic SzHx• 21 year old college student

• No prior neuro history

• Final exams, sleepless

• Great party after the last exam

• Pt with single generalized sz

• Seizure upon awakening


Juvenile Myoclonic SzPx• Vitals OK

• Neuro: slightly post-ictal

• Exam otherwise normal

• Patient has a 2nd seizure in the ED


Juvenile Myoclonic SzDx

• Juvenile myoclonic epilepsy

• Related to sleep deprivation, alcohol consumption

• Occurs upon awakening

• Responds best to valproate

• Phenytoin may exacerbate sx


Juvenile Myoclonic SzRx• Benzodiazepines to Rx the acute sz

• Ongoing protection an issue

• Valproate is likely the drug of choice

• Phenytoin may not be optimal

• Avoid status epilepticus


ConclusionsClinical Pearls• Acute, repetitive spells = sz

• Ongoing altered mental status = complex partial SE

• Treat acute szs with lorazepam

• Valproate is the etiology-specific ongoing Rx in many young people

• Know the specific JME clinical setting


RecommendationsManagement Implications

• Educate about sz etiologies

• Make multiple drugs available

• Alternate routes should be used

• A protocol should exist

• Utilize EEG when necessary

• Be aware of optimal Rx at disposition

Pediatric Seizure and Status Epilepticus Management in the Emergency Setting.

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