Transcript Status epilepticus the paeds emerg perspective

Status epilepticus
the paeds emerg perspective
Stephen C. Porter MD MPH MSc
Division Chief, Pediatric Emergency Medicine
The Hospital for Sick Children
Associate Professor of Paediatrics
University of Toronto School of Medicine
Outline for today
• Definitions
• ABCDs and parallel processing
• The pathway for status epilepticus at The
Hospital for Sick Children
• Scientific and artful considerations
Video tells the story
• http://www.youtube.com/watch?v=aL1cZqmk
C4A&feature=related
Definition of status epilepticus
• The International Classification of Epileptic
Seizures defines status epilepticus as a seizure
that lasts for a sufficient length of time (30
minutes or longer) or is repeated frequently
enough that the individual does not regain
consciousness between seizures
• Outcomes are worse for children with more
prolonged seizures – early treatment is key
ABCDs for status
Airway and breathing
Circulation and access
• Timely IV placement
• Alternatives
–
–
–
–
IO
Rectal
Intranasal
Intramuscular
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a
known seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
• Are anticonvulsant
levels sub-therapeutic?
• Obtain drug levels as
indicated
• Is it a breakthrough
seizure due to intercurrent illness?
• Evaluate for infection
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
Hypoglycemic seizure
Dextrose 0.25 – 1 g/kg
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
• Source of infection, in
particular meningitis
• Screening labs
• Need for LP?
• Empiric antibiotics after
blood/urine obtained?
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal
chemistries?
Are there focal neurologic
findings?
Electrolyte disturbance
Uremia
Hepatic failure
Metabolic derangement
Ingestion
Serum chemistries,
kidney function,
ammonia
Rapid assessment and treatment
For a child presenting in
status epilepticus
Are there signs of trauma?
Does the child have a known
seizure disorder?
Is the serum glucose low?
Is there fever?
Are there abnormal chemistries?
Are there focal neurologic
findings?
Mass lesion
Stroke
Brain abscess
CT scan of head
Pathway of care for status epilepticus
• Treatment should start when a seizure continues
longer than 5 minutes
• Continuous cardio-respiratory monitoring is essential.
• If IV access fails, consider other routes of delivery
• Fosphenytoin is generally preferred for the initial
loading dose over phenytoin or phenobarbital.
• If a patient is on phenytoin maintenance, consider
phenobarbital for the initial loading dose
• Most common errors
– Using too low of a dose for a benzodiazepine
– Delay in initiating second line treatment
The first 10 minutes
10 minutes  30 minutes
Refractory status
Scientific and artful – intranasal meds
•
•
•
•
•
•
•
Draw up the calculated dose of
midazolam PLUS an additional 0.1mL
(for priming) into a 1mL syringe
Attach atomizer (MAD Device) to the
1mL syringe
Prepare atomizer by slowing priming
(expelling air via the atomizer) the
additional 0.1mL of midazolam
Position patient either sitting up at
minimum of 45 degrees
Administer dose by inserting atomizer
into nostril loosely and aim for the
center of the nasal cavity
Doses with a volume greater than
0.5mL should be split between both
nostrils to prevent loss of solution
Depress plunger quickly
Scientific and artful – risk of meningitis
• There is an association between prolonged, focal or
recurrent seizures and meningitis
• Nigrovic et al validated and published a clinical prediction
rule stratifying risks for bacterial meningitis among children
with CSF pleocytosis; seizure was the only clinical predictor
• A child with a simple febrile seizure who recovers to a
normal mental status with a normal neurologic exam and
who is otherwise well is not at risk of meningitis
• A child with a complex febrile seizure who recovers to a
normal mental status with a normal neurologic exam and
who is otherwise well is at very low risk of meningitis
• For a child in status epilepticus who is febrile, obtain blood
cultures and treat with empiric doses of antibiotics
CFS by feature.
Kimia A et al. Pediatrics 2010;126:62-69
©2010 by American Academy of Pediatrics
Rates of CSF pleocytosis among patients with a CFS.
Kimia A et al. Pediatrics 2010;126:62-69
©2010 by American Academy of Pediatrics
Summary
• Doing the right thing for status epilepticus
– Emphasis on ABCDs (bag mask skills)
– Parallel processing: treat and diagnose
– Correct drugs in timely manner in right sequence
• Benzodiazepine (times two)
• Second line agent (usually fosphenytoin)
– System readiness to deliver a pathway of care