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  • 1.Shake & BakeShake & Bake Evaluation and Management of First Time PediatricEvaluation and Management of First Time Pediatric SeizuresSeizures Tricia Falgiani, MDTricia Falgiani, MD Assistant ProfessorAssistant Professor Department of Emergency MedicineDepartment of Emergency Medicine Division of Pediatric Emergency MedicineDivision of Pediatric Emergency Medicine

2. ObjectivesObjectives At the end of this session, the participant willAt the end of this session, the participant will be able to:be able to: Discuss indications for laboratory andDiscuss indications for laboratory and radiographic studies in a child with first timeradiographic studies in a child with first time afebrile seizure.afebrile seizure. Discuss indications for testing and treatment of aDiscuss indications for testing and treatment of a child with a febrile seizurechild with a febrile seizure Discuss the differences in evaluation andDiscuss the differences in evaluation and treatment of the very young infant with first timetreatment of the very young infant with first time seizures.seizures. 3. First Time SeizuresFirst Time Seizures Who cares?Who cares? Seizures are the most commonSeizures are the most common pediatric neurologic disorderpediatric neurologic disorder 4 6 % of children will have at least4 6 % of children will have at least one seizure in the first 16 years of lifeone seizure in the first 16 years of life The greatest incidence occurs in thoseThe greatest incidence occurs in those under 3 years of ageunder 3 years of age 4. Seizure DefinitionSeizure Definition A transient, involuntary alteration ofA transient, involuntary alteration of consciousness, behavior, motorconsciousness, behavior, motor activity, sensation, or autonomicactivity, sensation, or autonomic function caused by an excessive ratefunction caused by an excessive rate and hypersynchrony of dischargesand hypersynchrony of discharges from a group of cerebral neuronsfrom a group of cerebral neurons Friedman and Sharieff, Seizures in Children, Pediatr Clin N Am 53Friedman and Sharieff, Seizures in Children, Pediatr Clin N Am 53 (2006)(2006) 5. Pediatric SeizuresPediatric Seizures Differential DiagnosisDifferential Diagnosis Disorders with altered consciousnessDisorders with altered consciousness Apnea and syncopeApnea and syncope Breath-holding spellsBreath-holding spells Cardiac dysrhythmiasCardiac dysrhythmias Atypical migrainesAtypical migraines Gastroesophageal refluxGastroesophageal reflux 6. Pediatric SeizuresPediatric Seizures Differential DiagnosisDifferential Diagnosis Paroxysmal movement disordersParoxysmal movement disorders Acute dystoniaAcute dystonia Benign myoclonusBenign myoclonus PseudoseizuresPseudoseizures Shuddering attacksShuddering attacks Spasmus nutansSpasmus nutans TicsTics Sleep disordersSleep disorders Psychological disordersPsychological disorders 7. SeizuresSeizures TreatmentTreatment --Acute StabilizationAcute Stabilization Establish ABCsEstablish ABCs Consider IV glucose, naloxone, or pyridoxineConsider IV glucose, naloxone, or pyridoxine First dose of benzodiazepineFirst dose of benzodiazepine Phenytoin or Fosphenytoin (20 mg/kg IV)Phenytoin or Fosphenytoin (20 mg/kg IV) Phenobarbital (20mg/kg IV)Phenobarbital (20mg/kg IV) reassess, consider intubationreassess, consider intubation Continuous Infusion of BarbiturateContinuous Infusion of Barbiturate intubate nowintubate now General anesthesiaGeneral anesthesia 8. Nonfebrile SeizuresNonfebrile Seizures Practice ParameterPractice Parameter Based on recommendations publishedBased on recommendations published in Neurology in 2000in Neurology in 2000 Comprehensive review of 66 articlesComprehensive review of 66 articles Children 1 month 21 yearsChildren 1 month 21 years 1st time seizures not explained by1st time seizures not explained by immediate, obvious, provoking causeimmediate, obvious, provoking cause Seizure lasting < 30 minutesSeizure lasting < 30 minutes 9. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation EvidenceEvidence Eisner, et alEisner, et al 30 children (0-18) and 133 adults30 children (0-18) and 133 adults CBC, BMP, Ca, Mg doneCBC, BMP, Ca, Mg done 1 case of unsuspected hyperglycemia1 case of unsuspected hyperglycemia Turnbull, et alTurnbull, et al 136 new onset seizures136 new onset seizures No clinically significant lab abnormalities in theNo clinically significant lab abnormalities in the 16 children in the study (12-19 years old)16 children in the study (12-19 years old) 10. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation Evidence, cont.Evidence, cont. Larger retrospective studies (Nypaver et alLarger retrospective studies (Nypaver et al and Smith et al)and Smith et al) 507 children total- febrile and nonfebrile seizures507 children total- febrile and nonfebrile seizures Lab did not contribute to diagnosis orLab did not contribute to diagnosis or managementmanagement FarrarFarrar 47 infants < 6 months of age47 infants < 6 months of age 70% with hyponatremia70% with hyponatremia 11. Nonfebrile SeizuresNonfebrile Seizures Laboratory evaluationLaboratory evaluation RecommendationsRecommendations Laboratory tests should be ordered basedLaboratory tests should be ordered based on individual clinical circumstances thaton individual clinical circumstances that include suggestive historic or clinicalinclude suggestive historic or clinical findingsfindings (think hard about electrolytes in children under 6(think hard about electrolytes in children under 6 months of age)months of age) Toxicology screening should be consideredToxicology screening should be considered if there is any question of exposure orif there is any question of exposure or substance abusesubstance abuse 12. Nonfebrile SeizuresNonfebrile Seizures Lumbar PunctureLumbar Puncture EvidenceEvidence Rider et alRider et al 57 CSF samples in children with nonfebrile57 CSF samples in children with nonfebrile seizures (2-24 months old)seizures (2-24 months old) 12.3% with >5 leukocytes/mm312.3% with >5 leukocytes/mm3 None with meningitisNone with meningitis RecommendationRecommendation Lumbar Puncture is of limited value and shouldLumbar Puncture is of limited value and should only be used if there is clinical concern foronly be used if there is clinical concern for meningitis or encephalitismeningitis or encephalitis 13. Nonfebrile SeizuresNonfebrile Seizures EEGEEG EvidenceEvidence Multiple studiesMultiple studies EEGs are the best predictors of recurrence in childrenEEGs are the best predictors of recurrence in children who are neurologically normalwho are neurologically normal Helps determine seizure type, epilepsy syndrome andHelps determine seizure type, epilepsy syndrome and risk of recurrencerisk of recurrence Optimal timing is not clearOptimal timing is not clear RecommendationRecommendation The EEG is recommended as part of theThe EEG is recommended as part of the evaluation of the child with first timeevaluation of the child with first time nonprovoked seizures (nonprovoked seizures (StandardStandard)) 14. Nonfebrile SeizuresNonfebrile Seizures NeuroimagingNeuroimaging EvidenceEvidence Multiple studiesMultiple studies Abnormalities found in up to 1/3, but most did not influenceAbnormalities found in up to 1/3, but most did not influence management decisionsmanagement decisions 2% clinically significant findings2% clinically significant findings Most of those done because of focality of seizure or specificMost of those done because of focality of seizure or specific clinical findingsclinical findings EmergentEmergent imaging is to detect a serious condition that mayimaging is to detect a serious condition that may require immediate interventionrequire immediate intervention Non-urgentNon-urgent imaging detects abnormalities that may affectimaging detects abnormalities that may affect prognosis, and thus have an impact on long termprognosis, and thus have an impact on long term managementmanagement 15. Nonfebrile SeizuresNonfebrile Seizures ImagingImaging Sharma et alSharma et al 500 nonfebrile first time seizures500 nonfebrile first time seizures Mean age 46 months (0 21 years)Mean age 46 months (0 21 years) 95% were imaged95% were imaged 91% CT, 4% MRI91% CT, 4% MRI 83% normal83% normal 9% clinically insignificant abnormalities9% clinically insignificant abnormalities 8% (38 pts) clinically significant8% (38 pts) clinically significant Only 6 patients defined as low riskOnly 6 patients defined as low risk 16. Nonfebrile SeizuresNonfebrile Seizures ImagingImaging RecommendationsRecommendations If neuroimaging is obtained, MRI is preferred modalityIf neuroimaging is obtained, MRI is preferred modality ((guidelineguideline)) Emergent imagingEmergent imaging should be performed in a child whoshould be performed in a child who exhibits a post-ictal focal deficit not quickly resolving , orexhibits a post-ictal focal deficit not quickly resolving , or who does not return to baseline within several hourswho does not return to baseline within several hours ((optionoption)) Non-urgent imagingNon-urgent imaging with MRI should be considered in anywith MRI should be considered in any child with a significant cognitive or motor impairment ofchild with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities onunknown etiology, unexplained abnormalities on neurological exam, a seizure of partial (focal) onset, anneurological exam, a seizure of partial (focal) onset, an EEG that does not represent a benign partial epilepsy ofEEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in childrenchildhood or primary generalized epilepsy, or in children under 1 year of age. (under 1 year of age. (optionoption)) 17. Nonfebrile SeizuresNonfe

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