Transcript Pediatric Neurologic Emergencies

pediatric neurologic
emergencies
may 2002 core rounds
contents
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seizures
– approaches to
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febrile seizure
new onset non-febrile seizure
established seizure disorder with recurrence
neonatal seizures
status epilepticus
– investigation, treatment, disposition
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headache
– discussion (as little evidence to support)
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migraine treatment
imaging indications
case 1
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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
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approach?
– well looking child
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first event
multiple events
– sick looking child
case 2
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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
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approach?
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case 3
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16 year old
 known seizure disorder, on phenytoin
 typical seizure presenting complaint
 V/S N, neuro N, otherwise looks well
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approach?
case 4
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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
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approach?
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definitions
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febrile seizure – NIH defn - event of
infancy/childhood, typically between age
3mo and 5yrs, with no evidence intracranial
infection or defined cause
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epilepsy - two or more seizures not
provoked by a specific event such as fever,
trauma, infection, or chemical change
definitions
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neonatal seizure – in first 28 days of life
(typically first few days)
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status epilepticus
– seizure lasting >30 mins
 NB rosen 5-10 mins
– sequential seizures without regain LOC >30min
classification
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generalized
– LOC
– tonic, clonic, tonic-clonic, myoclonic, atonic, absence
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partial – focal onset
– simple partial – no LOC
– complex partial – LOC
– partial secondarily generalized
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unclassified
etiology
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infectious
 metabolic
 traumatic
 toxic
 neoplastic
 epileptic
 other
differential diagnosis
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syncope
 breath holding
 sleep disorders (eg. narcolepsy)
 paroxysmal movement disorder
– tics,tremors
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migraines
 psychogenic seizures
approach to febrile seizures
the numbers
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epidemiology
– 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 seizure
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< 15 mins
 no focal features
 no greater than 1 episode in 24h
 neurologically and developmentally normal
complex febrile seizure
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>15 min
– febrile epilepticus >30min or recurrent without
regaining consciousness > 30min
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focal
 recurrence within 24h
what do parents want to
know?
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recurrence
– risk recurrence 25-50%
– risk recurrence after 2nd – 50%
– most recurrences within 6-12 mo
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(20% within same febrile illness)
risk of epilepsy
– 2-3% (baseline 1%)
– increased in
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family history of epilepsy
abnormal developmental status
complex febrile seizure
neonatal seizure
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brief and subtle
– eye blinking
– mouth/tongue movements
– “bicycling” motion to limbs
typically sz’s can’t be provoked/consoled
 autonomic changes
 EEG less predictable
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neonatal seizure
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etiology
– hypoxic-ischemic encephalopathy
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Presents within first day
– congenital CNS anomalies
– intracranial hemorrhage
– electrolyte abnormalities – hypoglycemia and
hypocalcemia
– infections
– drug withdrawal
– pyrodoxine deficiency
status epilepticus
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definition
– deizure lasting >30 mins
 NB Rosen 5-10 mins
– sequential seizures without regain LOC >30min
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mortality in pediatric status epilepticus 4%
 morbidity may be as high as 30%
SE treatment considerations
ABC’s
 brief directed Hx and Px
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glucose
 antibiotics/antivirals
– if meningitis/encephalitis considered
SE treatment
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1st line anticonvulsants
– IV
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lorazepam 0.1mg/kg
diazepam 0.2 mg/kg
midazolam 0.2 mg/kg
– rectal diazepam
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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 treatment
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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)
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3rd line agents
– phenobarbital 20mg/kg @ 100mg/min
– repeat prn 5-10mg/kg
– maximum 40 mg/kg or 1 gram
refractory SE treatment
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consider midazolam
– 0.2 mg/kg bolus
– then 1-10 mcg/kg/min infusion
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induce barbiturate coma
– pentobarbital 5-15 mg/kg @ 25 mg/min
– then 1-5 mg/kg/hour
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others
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valproic acid
paraldehyde, chloral hydrate
propofol, inhalational anesthesia, paralysis
lidocaine
approach – stable post sz
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history
– pre-seizure
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what was child doing when attack occurred
precipitants – fever, trauma, poisoning, drug/med use
aura
– deizure
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what movements – incl. eyes
how long
LOC?
consequences – resp distress, incontinence, injury
– post seizure
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Post-ictal
approach to stable patient
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physical directed towards
– systemic disease
– infection
– toxic exposure
– focal neuro signs
laboratory
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blood glucose?
 electrolytes?
 magnesium, calcium?
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anything at all?
 what about first time seizures? recurrent?
laboratory
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yes if…
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neonatal
abnormal mental status persistent
diabetics, renal disease
diuretic use
dehydration
malnourishment
laboratory
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septic work-up (CBC, BC, urine C+S, CXR, LP)
– as indicated
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sick child
< 12 - 18 mo
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therapeutic drug levels
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other
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ABG
toxicologic screen
TORCH, ammonia, amino acids in neonate
CPK, lactate, prolactin – ?confirm seizure?
lumbar puncture
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patients at greatest risk for meningitis
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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
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The American Academy of Pediatrics
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“strongly consider” in infants under 12 months of age with a
first febrile seizure
neuroimaging
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WHO? which patients?
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WHAT? CT vs. MRI
– ultrasound in neonates
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WHEN? emergent vs. elective
ACEP guidelines - >6 yo
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consensus indication for non-contrast CT
first time seizure patients
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if suspect structural lesion
partial onset seizure
age > 40
no other identified cause
recurrent seizure patients
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change in pattern
prolonged post-ictal period
worsening mental status
neuroimaging
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predictors of abnormal findings of computed tomography of the head in
pediatric patients presenting with seizures
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Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23
– retrospective case series
– predicts CT scan results normal if
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no underlying high-risk condition
– malignancy, NCT, recent CHI, or recent CSF shunt revision
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older than 6 months
sustained a seizure of 15 minutes or less
no new-onset focal neurologic deficit
– not prospectively validated
emergent EEG?
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not generally available on emergent basis
 but consider in..
– persistent altered mental status (?non
convulsive status epilepticus)
– paralyzed patients
– pharmacologic coma
disposition
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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 – 1st non-febrile seizure
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follow-up EEG
– within 24h
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Lancet 1998;352:1007-11
improved pick-up 51% vs 34%
? how soon do we get ours ?
– inter-ictal EEG’s often normal
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neuro may do sleep deprivation study (provocation)
– absence epilepsy and infantile spasms are invariably
associated with an abnormal EEG
– spike and wave 3HZ
idiopathic seizure
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recurrence risk stratification
– normal EEG – 25%
– abN EEG – 60%
– 2nd seizure – 75%
neuroimaging
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MRI superior
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not emergently available
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?defer imaging until follow-up MRI
available in low risk patients?
treatment
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correct underlying pathology, if any
 antipyretics ineffective in febrile seizure
 anti-epileptic choice often trial and error
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no anti-epileptic 100% effective
febrile seizure – diazepam, phenobarbital, valproic acid
– Currently AAP does not recommend
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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 headache
case 5
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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
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approach?
– treatment
– imaging?
classification
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classify based on temporal pattern
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acute headaches
– any febrile illness, sinus/dental infection, intracranial
infection/bleed (AVM,SAH,trauma)
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acute recurrent
 chronic progressive
 chronic non-progressive
– tension, psychogenic, post-traumatic, ocular refractive
error
acute recurrent headache
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migraine
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other
– cluster headache – typically >10 yo
– sinusitis
– vascular malformation
migraine - terminology
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classic migraine
– biphasic
neuro aura
 headache, N/V, anorexia, photophobia
– either unilateral (older) / bilateral(younger) or both
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common migraine
– malaise, dizziness, N/V, feels and looks sick
– unilateral/bilateral
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migraine equivalent/”complicated migraine”
– transient neuro deficits
– +/- headache
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migraine variants
– Cyclic N/V, abdo pain
– BPV
migraine treatment
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very little supporting evidence for pharmacologic
treatment in children compared to adults
 classes of medication
– acetaminophen
– NSAIDS
– phenothiazines (dopamine antagonists)
– dihydroergotamine
– triptans
the simple stuff
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acetaminophen 15 mg/kg PO 30mg/kg PR
 ibuprofen 10 mg/kg PO
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Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of
migraine in children: A double-blind, randomized, placebo-controlled,
crossover study
Neurology 48:103-107, 1997
– N = 88 age 4-16
– relief at 2 hours
 acetaminophen 54%
 ibuprofen 68%
other NSAIDS
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naproxen 5-7 mg/kg PO
– no pediatric evidence
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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
dihydroergotamine
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not approved
 ?dose – 0.1 – 0.5 mg IV
 not studied in emergency population
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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
phenothiazines
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again no studies
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metoclopramide 1-2 mg/kg IV (max 10mg)
 prochloperazine 0.1 – 0.15 mg/kg
IV/IM/PO/PR (max 10mg)
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children may be more susceptible to EPS
– ? pre-treat with benadryl
triptans
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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
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sumitriptan intranasal
– long term treatment studies done
– no emergent studies
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triptans PO
– studies plagued by high placebo response
chronic progressive headache
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least common presentation
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most worrisome for increased ICP
– pseudotumor cerebri
– space occupying lesion
imaging indications? discuss
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lack of evidence to help
– small studies lack power to guide decision
making
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MRI preferred in non-urgent indication
imaging indications? discuss
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classically based on historical and physical
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sudden severe headache
rapid increase over days - weeks
chronic progressive
suggestive of increased ICP
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severe nocturnal headache (wakes or upon waking), changes in
pain with position, coughing
– following head trauma
– persistent neuro findings
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? include migraine equivalents ?
– growth abnormality
– age (? <3 ?)