Seizures  

Overview

•  5%  of  paeds  a+endances  to  ED  

Status Epilepticus

‘’generalised  convulsions  las7ng  30  minutes  or  longer’’  • or  ‘’failed  to  regain  consciousness  between  fits  over  30  minutes’’  

Why is SE important?

•  4%  mortality  

•  Significant  morbidity:  •  Epilepsy  •  Learning  difficul7es  •  Behavioural  problems  •  Motor  deficits  

Why is it important?

• Cerebral  autoregula7on  is  impaired  •  Compromises  blood  flow  

• Vicious  cycle  of  anaerobic  metabolism  and  lac7c  acidosis  •  Neuronal  cell  oedema/  death  •  Increased  intracranial  presssure    à  further  reduced  perfusion  

•  Systemic:  Leucocytosis,  acidosis,  DIC,  Rhabdomyolysis,  cardiac  dysfunc7on-­‐  pulmonary  oedema  

Neonates

•  Subtle  •  Motor  or  behavioural  or  autonomic  

• Hypoglycemia  <2mmol/L  •  Feeding  difficul7es,  sepsis  or  metabolic  disorders  •  ℞  2  ml/kg  of  10%  Glucose  iv  

• NAI  

Febrile seizures

•  6  months  to  6  years  •  Self-­‐limi7ng  <15  min  •  5%  with  status    

CNS infection

•  Febrile  CSE  •  Local  an7bio7c  policy  

•  Epilepsy  •  Not  everyone  with  seizures  has  epilepsy  •  h/o  AED-­‐  compliance,  change  or  withdrawal  

• Poisoning  

• Non-­‐convulsive  or  par7al  

Hx and examination

•  Focused  clinical  history  •  Simultaneously  assessing/managing  ABC  • Drug/allergy  hx  

• Directed  examina7on:  Meningism,  rash,  fever,  trauma  •  Thorough  examina7on  a]er  stabilisa7on-­‐  infec7on  screen,  neuro,  fundoscopy,  etc  

Mx

• Airway  manoeuvres  • NP  airway  (cau7on:  Head  injury)  

•  Reduced  LOC  à  intubate  

•  Simultaneous-­‐  iv  or  IO  access/  samples  •  VBG-­‐  glucose,  electrolytes,  mixed  metabolic  and  resp  acidosis  •  Bedside  BM  

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

•  Or  Diazepam  0.25  mg/kg  iv  

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

Lorazepam0.1 mg/kg IV/IO

Vascular Access?

STEP1

STEP2

STEP3

STEP4

5 minutes after convulsion started

Yes or canbe established quickly

If seizure is continuing 10 mins after start of step 1

Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

Prepare phenytoin

If seizure is continuing20 mins after the start of step 3 (start of infusion)

– an anaesthetist MUST be present

If seizure is continuing10 mins after the start of step 2

– reconfirm it is an epileptic seizure

AirwayHigh-flow oxygen

Don’t ever forget glucose

Lorazepam0.1 mg/kg IV/IO

Call for senior help

RSI with Thiopental (Thiopentone)

Senior help is now neededSeek anaesthetic/ICU advice

Phenytoin 20 mg/kg IV/IO over 20 min

Midazolam (buccal)0.5 mg/kg or

Diazepam (rectal)0.5 mg/kg

A charity dedicated to saving lifeby providing training

AdvancedLifeSupportGroup

No

Figure 10.1. Status epilepticus treatment algorithm (reproduced with kind permission of the Advanced LifeSupport Group).

100 Section 2: Clinical Conditions

CSE

•  Longer    a  fit  con7nues,  more  difficult  it  can  be  to  terminate  • More  likely  to  intubate  •  Think  ahead  and  have  essen7al  drugs  •  Senior  anaesthe7c  help  sooner  

• Phenytoin  alternate:    •  Phenobarbitone  •  Leve7racetam  •  Valproate  

Intubation and sedation

• RSI-­‐  thiopentone  • Morphine  and  Midazolam  infusion  •  Short  ac7ng  relaxant  • D/w  PICU  •  Further  seizures-­‐  further  AED;  midaz  bolus;  double  M+M  rate  

• Reassess;  review  blood  reports;  CT;  NGT  • Normothermia/carbia/glycaemia/30’headup  

Further after I&V

•  Seizure  controlled  and  cause  corrected  •  Extubate  or  transfer  •  d/w  ter7ary  centre  •  Depending  on  age,  cause,  ward  and  medical  cover  •  Minimise  delay  of  transfer  

Summary

• Management  is  highly  protocolised  •  Early  VBG  and  don’t  forget  glucose  • Decisive  and  7mely  interven7on  could  prevent  long-­‐term  injury.