Seizures - Yale medStation

Report
Seizures:
Nuts and Bolts
National Pediatric Nighttime Curriculum
Written by Anna Lin, MD
Lucile Packard Children’s Hospital
Learning Objectives
Understand the importance of initial
assessment of patients who have seizures
 Be able to initiate treatment for patients
who have seizures
 Know alternatives to first line treatments
for status epilepticus

Case #1

14-month-old developmentally normal
boy who presents with generalized
tonic-clonic seizures associated with
fever.
 How
would you initiate management?
 What other information would be useful to
you as you are starting to intervene?
 What type of work-up does this patient
need?
Case # 2

12-year-old boy with obstructive
hydrocephalus and VP shunt who
presents with generalized tonic-clonic
seizures for the past 15 minutes.
 How
would you initiate management?
 What other information would be useful to you
as you are starting to intervene?
 What type of work-up does this patient need?
Types of Seizure

Partial Seizures
 Simple
vs. Complex
 Different types (motor, sensory, autonomic,
“psychic”)

Generalized Seizures
 Convulsive
vs. Nonconvulsive
 Secondarily generalized vs. Secondary
Status Epilepticus

A patient is in status epilepticus if seizure
activity has lasted > 30 minutes or there
are multiple seizure episodes with failure
to regain consciousness between
episodes

This is an arbitrary definition
Management of Seizures
Initial assessment
Airway
Breathing
Circulation
 Call for help
Hospitalist
Neuro
PICU/RRT


Ask for more history
 How
long has the
patient been seizing?
 New-onset vs. known
seizure disorder
 Baseline seizure
frequency, is this
typical or not?
 Events leading up to
this episode
 Meds/triggers
 History of status
Management of Seizures

Consider rapid work-up for underlying
etiologies
 CNS
infection
 Acute HIE
 Metabolic disease
 Electrolyte imbalance
 TBI
 Drugs, intoxications, poisonings
 Cerebrovascular event
Benzodiazepines

Lorazepam (Ativan)

0.05-0.1 mg/kg IV q10-15 min, max dose 4 mg


Less respiratory depression than diazepam, longer
duration of action, slower onset (2 min)
Midazolam (Versed)
 0.15
mg/kg IV then continuous infusion of 1
mcg/kg/min


Other formulations available: IM, buccal, intranasal,
oral, and rectal
Short half life, faster onset (1 min)
Benzodiazepines (2)

Diazepam (Valium)
 0.05-0.3
mg/kg IV q15-30 min, max dose 10
mg
Quick onset (10-20 sec), rectal formulation, higher
risk of respiratory depression
 Not considered first line
 Lower efficacy
 Increased respiratory depression

Fosphenytoin/Phenytoin

Fosphenytoin (Cerebyx)
 15-20
mg PE/kg IV/IM, may infuse 3 mg/kg/min (max
150 mg/min), max dose 1500 mg PE/24 hours





Prodrug of phenytoin which has fewer side effects
Can cause cardiac arrhythmias
Avoid for status with myoclonic seizures or absence seizures
Consider alternatives in seizures associated with illicit drug
use
Phenytoin (Dilantin)
 Not used first line as there are many side effects
 Cardiac arrhythmias/hypotension associated with propylene
glycol used to dissolve phenytoin
 Local pain, venous thrombosis and purple glove syndrome 
skin necrosis, limb ischemia  amputation
Barbiturates

Phenobarbital (Luminal)
 15-20
mg/kg IV/IM, may repeat 5 mg/kg IV q1530 min, max dose 40 mg/kg

Prolonged sedation, respiratory depression,
hypotension
 Generally
used after failure of benzodiazepines
and fosphenytoin

Pentobarbital (Nembutal)
 12

mg/kg IV followed by 5 mg/kg/hr infusion
Titrate to EEG inactivity
 Used
for refractory status epilepticus
Other agents

Propofol (Diprivan)
 Rapid
onset, short duration of action
 Mechanism of action is unclear
 Hypotension, apnea and bradycardia are common
 Intubation and ventilation are required for the
use of this medication
 Prolonged use can result in hypertriglyceridemia and
pulmonary edema
 Associated with fatal acidosis and rhabdomyolysis
Other agents (2)

AEDs with some data to suggest use in
refractory SE
 Valproic
acid (Depakote): not yet approved
for SE, some data to support its use
 Topiramate (Topamax): PO only
 Levetiracetam (Keppra): adult data only
References



AAP Subcommittee on Febrile Seizures. Clinical
Practice Guideline—Neurodiagnostic Evaluation
of the Child With a Simple Febrile Seizure.
Pediatrics 2011, 127(2): 389-394
Singh RK, Gaillard WD. Status Epilepticus in
Children. Current Neurology and Neuroscience
Reports 2009, 9:137–144
Wilfong A. Overview of the classification, etiology,
and clinical features of pediatric seizures and
epilepsy. Up To Date, 2011.
Questions
1. You are paged by the nurse to come to the bedside of a
patient with known seizure disorder who is actively seizing.
On arrival to the bedside, you note that the patient is having
tonic-clonic movements of all extremities, upward eye
deviation, and frothing at the mouth. The next step in the
assessment/management of this patient is to
A.Ask the nurse how long the patient has been seizing
B.Wait for your senior resident to come and assist you
C.Have the nurse give lorazepam through the IV
D.Suction and secure the airway
E.Obtain a fingerstick blood glucose
Questions
D.Suction and secure the airway
In all patients, the first assessment you make should
be checking airway, breathing and circulation. Although
you should call for help, you do not need to wait to start lifesaving interventions. While lorazepam is an excellent antiseizure medication, if your airway is not secure, you could
risk putting this patient into respiratory failure. Asking for
more information can be helpful in overall management, but
is not the next best step. You can consider hypoglycemia
as an underlying etiology, but this is also not the first step in
your assessment.
Questions
2.You are called to the Emergency Department to admit a 2year-old patient who had a 2 minute generalized tonicclonic seizure associated with fever. The patient is wellappearing and at baseline neurological status 30 minutes
after the event. His neurological examination is normal.
What should you do?
A.Discharge the patient home after seizure education.
B.Admit the patient to the floor for overnight
observation.
C.Recommend the Emergency Department obtain a
head CT.
D.Obtain screening labs including a CBCD, chemistry
panel and CRP.
E.Discharge the patient home with rectal diazepam.
Questions
A.Discharge the patient home after seizure education.
This patient has had a simple febrile seizure. The general
course of this disease process is benign. It needs no further
work-up. Use of anti-epileptic medications is not indicated in
simple febrile seizures. Admission is not necessary. Parents
should be reassured about this incident and given education
about recurrence risk and when to activate the emergency
medical system (i.e. call 911).
Questions
3. All the following medications are used to treat
status epilepticus EXCEPT
A.Lorazepam
B.Fosphenytoin
C.Phenobarbital
D.Propofol
E.Levetiracetam
Questions
E.Levetiracetam
Levetiracetam (Keppra) is not routinely used to treat
status epilepticus. Although there is some adult
data to support its use, its use in pediatrics is not
widespread. Other medications which are not
routinely used in the treatment of status epilepticus
in the pediatric population include valproic acid and
topiramate. These medications may be used in
refractory status epilepticus.
Questions
4. A 3-year-old boy with known seizure disorder is
being admitted for increased seizure frequency.
As you assess the patient, he develops
generalized tonic-clonic seizures. He is
maintaining his airway and oxygen saturation is
94% on RA. He is afebrile. He does not have IV
access. What would you do next?
A.Administer buccal midazolam.
B.Order an emergent head CT.
C.Check electrolytes and glucose STAT.
D.Obtain more history.
E.Start a peripheral IV.
Questions
D.Obtain more history.
Since there is no vital sign instability, the patient does not require
immediate treatment. This seizure may represent be typical for him.
Important history to obtain includes frequency and type of seizures,
medication history (what type of anti-epileptic therapy is the patient
on and how often does he take it, has he missed any doses), any
triggers for seizures/new exposures, previous history of status
epilepticus and other recent events or symptoms.
Administration of buccal midazolam is not indicated if the seizure
normally resolves within a few minutes. The patient may require
further brain imaging. In a patient with known seizure disorder and
no history of trauma or increased ICP, emergent head CT may
expose the patient unnecessarily to high doses of radiation. MRI of
the brain may the imaging modality of choice, but does not need to be
performed emergently. Starting a peripheral IV and checking labs
could be useful but are not the next steps in the evaluation of this
patient.
Questions
5.Which of the following is TRUE about
fosphenytoin/phenytoin?
A.Phenytoin is used first-line in status
epilepticus.
B.Phenytoin can cause cardiac arrhythmia,
but fosphenytoin does not.
C.The loading dose of fosphenytoin is 20
mg/kg PE IV or IM.
D.Fosphenytoin is best used for patients with
myoclonic or absence seizures.
E.Phenytoin is a prodrug.
Questions
C.The loading dose of fosphenytoin is 20 mg/kg PE
IV or IM.
Fosphenytoin is ordered in mg PE (phenytoin
equivalents). It is a prodrug which is converted into
phenytoin. It can cause cardiac arrhythmias
although less commonly than phenytoin. Phenytoin
should be avoided in patients with myoclonic or
absence status epilepticus. Phenytoin is not used
first-line because of its cardiac arrhythmias and risk
of venous thrombosis.

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