pediatric neurologic pediatric neurologic emergenciesemergencies

may 2002 core rounds

contentscontents

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 1case 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 2case 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 3case 3

16 year oldknown seizure disorder, on phenytointypical seizure presenting complaintV/S N, neuro N, otherwise looks well

approach?

case 4case 4

2 week old parents - “doesn’t 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?

definitionsdefinitions

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

definitionsdefinitions

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

classificationclassification

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

partial – focal onset– simple partial – no LOC– complex partial – LOC– partial secondarily generalized

unclassified

etiologyetiology

infectiousmetabolictraumatictoxicneoplasticepilepticother

differential diagnosisdifferential diagnosis

syncopebreath holdingsleep disorders (eg. narcolepsy)paroxysmal movement disorder

– tics,tremors

migrainespsychogenic seizures

approach to febrile seizuresapproach to febrile seizuresthe numbersthe numbersepidemiology

– 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 seizuresimple febrile seizure

< 15 minsno focal featuresno greater than 1 episode in 24hneurologically and developmentally normal

complex febrile seizurecomplex febrile seizure

>15 min– febrile epilepticus >30min or recurrent without

regaining consciousness > 30min

focal recurrence within 24h

what do parents want to what do parents want to know?know? recurrence

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

(20% within same febrile illness)

risk of epilepsy– 2-3% (baseline 1%)– increased in

family history of epilepsy abnormal developmental status complex febrile seizure

neonatal seizureneonatal seizure

brief and subtle– eye blinking– mouth/tongue movements– “bicycling” motion to limbs

typically sz’s can’t be provoked/consoledautonomic changesEEG less predictable

neonatal seizureneonatal 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 epilepticusstatus 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 considerationsSE treatment considerations

ABC’sbrief directed Hx and Px

glucose antibiotics/antivirals

– if meningitis/encephalitis considered

SE treatmentSE 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 treatmentSE 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 treatmentrefractory 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 szapproach – 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 patientapproach to stable patient

physical directed towards– systemic disease– infection– toxic exposure– focal neuro signs

laboratorylaboratory

blood glucose? electrolytes? magnesium, calcium?

anything at all? what about first time seizures? recurrent?

laboratorylaboratory

yes if…– neonatal– abnormal mental status persistent– diabetics, renal disease– diuretic use– dehydration– malnourishment

laboratorylaboratory

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 puncturelumbar 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

neuroimagingneuroimaging

WHO? which patients?

WHAT? CT vs. MRI– ultrasound in neonates

WHEN? emergent vs. elective

ACEP guidelines - >6 yoACEP 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

neuroimagingneuroimaging 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?emergent EEG?

not generally available on emergent basisbut consider in..

– persistent altered mental status (?non convulsive status epilepticus)

– paralyzed patients– pharmacologic coma

dispositiondisposition

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 – 1EEG – 1stst non-febrile seizure 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 EEG’s 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 seizureidiopathic seizure

recurrence risk stratification – normal EEG – 25%– abN EEG – 60%– 2nd seizure – 75%

neuroimagingneuroimaging

MRI superior

not emergently available

?defer imaging until follow-up MRI available in low risk patients?

treatmenttreatment

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 neonatal - phenobarbital generalized TC – phenytoin, phenobarbital, carbamazepine, valproic

acid, primidone absence – ethosuximide, valproic acid new anti-epileptics – felbamate, gabapentin, lamotrigine, topiramate,

tiagabine, vigabatrine

in consultation with neurologist

pediatric headachepediatric headache

case 5case 5

14 year old mother’s 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?

classificationclassification

classify based on temporal pattern

acute 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 headacheacute recurrent headache

migraine

other– cluster headache – typically >10 yo– sinusitis– vascular malformation

migraine - terminologymigraine - 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 treatmentmigraine 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 stuffthe 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, placebo-controlled, crossover studyNeurology 48:103-107, 1997 – N = 88 age 4-16– relief at 2 hours

acetaminophen 54% ibuprofen 68%

other NSAIDSother 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

dihydroergotaminedihydroergotamine

not approved?dose – 0.1 – 0.5 mg IVnot 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

phenothiazinesphenothiazines

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

triptanstriptans

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 headachechronic progressive headache

least common presentation

most worrisome for increased ICP– pseudotumor cerebri– space occupying lesion

imaging indications? discussimaging indications? discuss

lack of evidence to help– small studies lack power to guide decision

making

MRI preferred in non-urgent indication

imaging indications? discussimaging 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 ?)