pediatric neurologic emergencies

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pediatric neurologic emergencies

• may 2002 core rounds

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contents

• seizures
• approaches to
• febrile seizure
• new onset non-febrile seizure
• established seizure disorder with recurrence
• neonatal seizures
• status epilepticus
• investigation, treatment, disposition
• headache
• discussion (as little evidence to support)
• migraine treatment
• imaging indications

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case 1

• 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
• approach?
• well looking child
• first event
• multiple events
• sick looking child

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case 2

• 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
• approach?

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case 3

• 16 year old
• known seizure disorder, on phenytoin
• typical seizure presenting complaint
• V/S N, neuro N, otherwise looks well
• approach?

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case 4

• 2 week old
• parents - doesnt 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
• approach?

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definitions

• febrile seizure NIH defn - event of
  infancy/childhood, typically between age 3mo and
  5yrs, with no evidence intracranial infection or
  defined cause
• epilepsy - two or more seizures not provoked by a
  specific event such as fever, trauma, infection,
  or chemical change

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definitions

• neonatal seizure in first 28 days of life
  (typically first few days)
• status epilepticus
• seizure lasting gt30 mins
• NB rosen 5-10 mins
• sequential seizures without regain LOC gt30min

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classification

• generalized
• LOC
• tonic, clonic, tonic-clonic, myoclonic, atonic,
  absence
• partial focal onset
• simple partial no LOC
• complex partial LOC
• partial secondarily generalized
• unclassified

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etiology

• infectious
• metabolic
• traumatic
• toxic
• neoplastic
• epileptic
• other

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differential diagnosis

• syncope
• breath holding
• sleep disorders (eg. narcolepsy)
• paroxysmal movement disorder
• tics,tremors
• migraines
• psychogenic seizures

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approach to febrile seizuresthe numbers

• 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

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simple febrile seizure

• lt 15 mins
• no focal features
• no greater than 1 episode in 24h
• neurologically and developmentally normal

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complex febrile seizure

• gt15 min
• febrile epilepticus gt30min or recurrent without
  regaining consciousness gt 30min
• focal
• recurrence within 24h

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what do parents want to know?

• recurrence
• risk recurrence 25-50
• risk recurrence after 2nd 50
• most recurrences within 6-12 mo
• (20 within same febrile illness)
• risk of epilepsy
• 2-3 (baseline 1)
• increased in
• family history of epilepsy
• abnormal developmental status
• complex febrile seizure

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neonatal seizure

• brief and subtle
• eye blinking
• mouth/tongue movements
• bicycling motion to limbs
• typically szs cant be provoked/consoled
• autonomic changes
• EEG less predictable

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neonatal seizure

• etiology
• hypoxic-ischemic encephalopathy
• Presents within first day
• congenital CNS anomalies
• intracranial hemorrhage
• electrolyte abnormalities hypoglycemia and
  hypocalcemia
• infections
• drug withdrawal
• pyrodoxine deficiency

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status epilepticus

• definition
• deizure lasting gt30 mins
• NB Rosen 5-10 mins
• sequential seizures without regain LOC gt30min
• mortality in pediatric status epilepticus 4
• morbidity may be as high as 30

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SE treatment considerations

• ABCs
• brief directed Hx and Px
• glucose
• antibiotics/antivirals
• if meningitis/encephalitis considered

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SE treatment

• 1st line anticonvulsants
• IV
• lorazepam 0.1mg/kg
• diazepam 0.2 mg/kg
• midazolam 0.2 mg/kg
• rectal diazepam
• 2-5 yrs 0.5 mg/kg
• 6-11 yrs 0.3 mg/kg
• gt12 yrs 0.2 mg/kg
• IM, intranasal, buccal midazolam

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SE treatment

• 2nd line agents
• phenytoin 20 mg/kg _at_ 1mg/kg/min (upto 50 mg/min)
• fosphenytoin 15-20 PE/kg _at_ 3 mg/kg/min (upto 150
  mg/min)
• 3rd line agents
• phenobarbital 20mg/kg _at_ 100mg/min
• repeat prn 5-10mg/kg
• maximum 40 mg/kg or 1 gram

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refractory SE treatment

• consider midazolam
• 0.2 mg/kg bolus
• then 1-10 mcg/kg/min infusion
• induce barbiturate coma
• pentobarbital 5-15 mg/kg _at_ 25 mg/min
• then 1-5 mg/kg/hour
• others
• valproic acid
• paraldehyde, chloral hydrate
• propofol, inhalational anesthesia, paralysis
• lidocaine

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approach stable post sz

• history
• pre-seizure
• what was child doing when attack occurred
• precipitants fever, trauma, poisoning, drug/med
  use
• aura
• deizure
• what movements incl. eyes
• how long
• LOC?
• consequences resp distress, incontinence,
  injury
• post seizure
• Post-ictal

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approach to stable patient

• physical directed towards
• systemic disease
• infection
• toxic exposure
• focal neuro signs

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laboratory

• blood glucose?
• electrolytes?
• magnesium, calcium?
• anything at all?
• what about first time seizures? recurrent?

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laboratory

• yes if
• neonatal
• abnormal mental status persistent
• diabetics, renal disease
• diuretic use
• dehydration
• malnourishment

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laboratory

• septic work-up (CBC, BC, urine CS, CXR, LP)
• as indicated
• sick child
• lt 12 - 18 mo
• therapeutic drug levels
• other
• ABG
• toxicologic screen
• TORCH, ammonia, amino acids in neonate
• CPK, lactate, prolactin ?confirm seizure?

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lumbar puncture

• patients at greatest risk for meningitis
• 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
• The American Academy of Pediatrics
• strongly consider in infants under 12 months of
  age with a first febrile seizure

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neuroimaging

• WHO? which patients?
• WHAT? CT vs. MRI
• ultrasound in neonates
• WHEN? emergent vs. elective

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ACEP guidelines - gt6 yo

• consensus indication for non-contrast CT
• first time seizure patients
• if suspect structural lesion
• partial onset seizure
• age gt 40
• no other identified cause
• recurrent seizure patients
• change in pattern
• prolonged post-ictal period
• worsening mental status

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neuroimaging

• predictors of abnormal findings of computed
  tomography of the head in pediatric patients
  presenting with seizures
• Warden CR - Ann Emerg Med - 01-Apr-1997 29(4)
  518-23
• retrospective case series
• predicts CT scan results normal if
• no underlying high-risk condition
• malignancy, NCT, recent CHI, or recent CSF shunt
  revision
• older than 6 months
• sustained a seizure of 15 minutes or less
• no new-onset focal neurologic deficit
• not prospectively validated

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emergent EEG?

• not generally available on emergent basis
• but consider in..
• persistent altered mental status (?non convulsive
  status epilepticus)
• paralyzed patients
• pharmacologic coma

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disposition

• can be discharged home if
• single seizure
• stable, returning to baseline neuro status
• no underlying condition/cause requiring treatment
  in hospital
• arranged follow-up

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EEG 1st non-febrile seizure

• follow-up EEG
• within 24h
• Lancet 19983521007-11
• improved pick-up 51 vs 34
• ? how soon do we get ours ?
• inter-ictal EEGs often normal
• neuro may do sleep deprivation study
  (provocation)
• absence epilepsy and infantile spasms are
  invariably associated with an abnormal EEG
• spike and wave 3HZ

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idiopathic seizure

• recurrence risk stratification
• normal EEG 25
• abN EEG 60
• 2nd seizure 75

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neuroimaging

• MRI superior
• not emergently available
• ?defer imaging until follow-up MRI available in
  low risk patients?

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treatment

• correct underlying pathology, if any
• antipyretics ineffective in febrile seizure
• anti-epileptic choice often trial and error
• no anti-epileptic 100 effective
• febrile seizure diazepam, phenobarbital,
  valproic acid
• Currently AAP does not recommend
• 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

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pediatric headache
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case 5

• 14 year old
• mothers chief complaint - having headaches all
  the time, getting worse, this is not normal!!
  etc. etc..
• V/S N
• looks in discomfort but otherwise well
• approach?
• treatment
• imaging?

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classification

• classify based on temporal pattern
• acute headaches
• any febrile illness, sinus/dental infection,
  intracranial infection/bleed (AVM,SAH,trauma)
• acute recurrent
• chronic progressive
• chronic non-progressive
• tension, psychogenic, post-traumatic, ocular
  refractive error

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acute recurrent headache

• migraine
• other
• cluster headache typically gt10 yo
• sinusitis
• vascular malformation

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migraine - terminology

• classic migraine
• biphasic
• neuro aura
• headache, N/V, anorexia, photophobia
• either unilateral (older) / bilateral(younger) or
  both
• common migraine
• malaise, dizziness, N/V, feels and looks sick
• unilateral/bilateral
• migraine equivalent/complicated migraine
• transient neuro deficits
• /- headache
• migraine variants
• Cyclic N/V, abdo pain
• BPV

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migraine treatment

• very little supporting evidence for pharmacologic
  treatment in children compared to adults
• classes of medication
• acetaminophen
• NSAIDS
• phenothiazines (dopamine antagonists)
• dihydroergotamine
• triptans

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the simple stuff

• acetaminophen 15 mg/kg PO 30mg/kg PR
• ibuprofen 10 mg/kg PO
• Hamalainen ML Ibuprofen or acetaminophen for the
  acute treatment of migraine in children A
  double-blind, randomized, placebo-controlled,
  crossover study
• Neurology 48103-107, 1997
• N 88 age 4-16
• relief at 2 hours
• acetaminophen 54
• ibuprofen 68

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other NSAIDS

• naproxen 5-7 mg/kg PO
• no pediatric evidence
• ketorolac IV 0.5 mg/kg (max 30mg dose)
• not studied in pediatric migraine
• not approved lt16 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

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dihydroergotamine

• not approved
• ?dose 0.1 0.5 mg IV
• not studied in emergency population
• 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

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phenothiazines

• again no studies
• metoclopramide 1-2 mg/kg IV (max 10mg)
• prochloperazine 0.1 0.15 mg/kg IV/IM/PO/PR (max
  10mg)
• children may be more susceptible to EPS
• ? pre-treat with benadryl

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triptans

• 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 36419422,
  1996
• N 50 age 6-18
• 78 effective at 2 hours
• 6 recurrence
• sumitriptan intranasal
• long term treatment studies done
• no emergent studies
• triptans PO
• studies plagued by high placebo response

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chronic progressive headache

• least common presentation
• most worrisome for increased ICP
• pseudotumor cerebri
• space occupying lesion

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imaging indications? discuss

• lack of evidence to help
• small studies lack power to guide decision making
• MRI preferred in non-urgent indication

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imaging indications? discuss

• classically based on historical and physical
• sudden severe headache
• rapid increase over days - weeks
• chronic progressive
• suggestive of increased ICP
• severe nocturnal headache (wakes or upon waking),
  changes in pain with position, coughing
• following head trauma
• persistent neuro findings
• ? include migraine equivalents ?
• growth abnormality
• age (? lt3 ?)