Difference between revisions of "Pediatric Seizures"

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'''Definition:'''
 
<br/>Disease of the brain defined by any of the following conditions
 
*A least two unprovoked (or reflex) seizures occurring >24 h apart
 
*One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
 
*Diagnosis of an epilepsy syndrome
 
*Provoked seizures are not epilepsy (e.g. febrile seizures, convulsive syncope)
 
 
 
'''Epidemiology of Epilepsy:'''  
 
'''Epidemiology of Epilepsy:'''  
 
*Incidence: averages ~150,000 or 48 per 100,000 people each year
 
*Incidence: averages ~150,000 or 48 per 100,000 people each year
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*In 2015: 1.2% US population had active epilepsy
 
*In 2015: 1.2% US population had active epilepsy
 
**Alaska:7,200 (1,100 children, 6,100 adults)
 
**Alaska:7,200 (1,100 children, 6,100 adults)
 
'''Seizure Types:'''
 
*Focal Onset
 
**aware/impaired Awareness
 
**motor (automatisms, atonic, tonic) or nonmotor onset
 
*Generalized Onset
 
**motor (tonic-clonic, atonic) or nonmoto (absence)
 
*Unknown onset
 
 
'''Critical Times for Affected Patients:'''
 
*Mortality rate associated with seizures lasting >30 minutes as high as 19%
 
*'''Status Epilepticus (SE):'''
 
**Tonic-clonic (>5 min)
 
**Focal SE with impaired �consciousness (>10 min)
 
**Absence SE (>10-15 min)
 
  
 
'''Diagnosis:'''
 
'''Diagnosis:'''
*clinical (rhythmic/repetative movements, elevated heart rate) or by EEG (must refer to ANMC)
+
*Look for Causes:
*Causes:
+
**history of epilepsy or seizure disorder
**history of epilepsy
 
 
**febrile/FIRES (Febrile infection-related epilepsy syndrome)
 
**febrile/FIRES (Febrile infection-related epilepsy syndrome)
 
**metabolic abnormalities (low or high Na, low Ca2+, low or high glucose, low Magnesium)
 
**metabolic abnormalities (low or high Na, low Ca2+, low or high glucose, low Magnesium)
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**Infection
 
**Infection
 
**trauma
 
**trauma
**severe breath holding
+
**Severe Breath Holding:  Consider this etiology if the child was crying very hard, held his breath, turned red/purple (occasionally blue), and then passed out with seizure-like activity
***Consider this cause if the child was crying very hard, held his breath, turned red/purple (occasionally blue), and then passed out with seizure-like activity
+
 
 +
'''Critical Times for Affected Patients:'''
 +
*Mortality rate associated with seizures lasting >30 minutes as high as 19%
 +
*'''Status Epilepticus (SE):''' Tonic-clonic (>5 min), Focal SE with impaired consciousness (>10 min), Absence SE (>10-15 min)
 +
*For all children at least 6months old or older who live in the village presenting with seizure activity, strongly consider dispensing an appropriate dose of Rectal Diastat upon discharge to the village.  While village clinics are supposed to be stocked with midazolam, fosphenytoin, and phenobarbital; they may have used these medications and not had time to restock due to weather delay or recent use.  The Rectal Diastat may be the only Antiseizure medication available in the village to treat your patient in status epilepticus.
  
 
'''Management:'''
 
'''Management:'''
See [[media:Seizure_treatment_peds.pdf|Seizure Treatment (Pediatrics) YKHC Clinical Guideline]]
+
*See [[media:Seizure_treatment_peds.pdf|Seizure Treatment (Pediatrics) YKHC Clinical Guideline]]
 +
*see [[Seizures RMT]] for recommendations on how to treat status epilepticus in the villages
 +
*[[Pharmacy Things to Know#Pediatric Seizure Kit|Pediatric Seizure Kit]] (available from ED and NW peds Pyxis)
 +
*Collaboration with Anchorage Neurologists (Drs. Smith and Devine), SCH neurologists, and Providence and ANMC PICU attendings (see PEDS Reference Phone Numbers list for contact information)
  
'''Complications (Epilepsy):'''
+
'''Morbidity (Epilepsy or prolonged status epilepticus):'''
 
*Focal neurologic deficits
 
*Focal neurologic deficits
 
*Cognitive Impairment
 
*Cognitive Impairment
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===Resources/References===
 
===Resources/References===
 +
* [https://www.cdc.gov/mmwr/volumes/66/wr/pdfs/mm6631a1.pdf National and State Estimates of the Numbers of Adults and Children with Active Epilepsy — United States, 2015].  CDC. (2017).
 +
* Glauser, et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4749120/ Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society]. ''Epilepsy Curr''. 2016 Jan-Feb; 16(1): 48–61. doi: 10.5698/1535-7597-16.1.48
 +
* Sharge, et al. [https://pediatrics.aappublications.org/content/145/6/e20193182 Levetiracetam Versus Phenobarbital for Neonatal Seizures: A Randomized Controlled Trial]. ''Pediatrics'' Jun 2020, 145 (6) e20193182; DOI: 10.1542/peds.2019-3182
 +
*Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R; NETT and PECARN Investigators. [https://www.nejm.org/doi/full/10.1056/NEJMoa1905795 Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus]. ''N Engl J Med''. 2019 Nov 28;381(22):2103-2113. doi: 10.1056/NEJMoa1905795. PMID: 31774955; PMCID: PMC7098487.
 +
* Singh A, Stredny CM, Loddenkemper T. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6982635/ Pharmacotherapy for Pediatric Convulsive Status Epilepticus]. ''CNS Drugs''. 2020;34(1):47-63. doi:10.1007/s40263-019-00690-8
 +
* Burman, Richard J et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6530138/ A Comparison of Parenteral Phenobarbital vs. Parenteral Phenytoin as Second-Line Management for Pediatric Convulsive Status Epilepticus in a Resource-Limited Setting]. ''Frontiers in neurology'' vol. 10 506. 15 May. 2019, doi:10.3389/fneur.2019.00506
 +
*Fletcher EM, Sharieff G. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3656699/ Necessity of lumbar puncture in patients presenting with new onset complex febrile seizures]. West J Emerg Med. 2013;14(3):206-211. doi:10.5811/westjem.2012.8.12872
 +
*Son YY, Kim GH, Byeon JH, Eun SH, Eun BL. [https://journals.lww.com/pec-online/Abstract/2018/03000/Need_for_Lumbar_Puncture_in_Children_Younger_Than.14.aspx Need for Lumbar Puncture in Children Younger Than 12 Months Presenting With Simple Febrile Seizure]. Pediatr Emerg Care. 2018 Mar;34(3):212-215. doi: 10.1097/PEC.0000000000000779. PMID: 27404463.
 +
*Najaf-Zadeh, Abolfazl et al. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557257/ Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis.] PloS one vol. 8,1 (2013): e55270. doi:10.1371/journal.pone.0055270
 +
*Dubos F, De la Rocque F, Levy C, Bingen E, Aujard Y, Cohen R, Bréart G; Bacterial Meningitis Study Group, Gendrel D, Chalumeau M. [https://pubmed.ncbi.nlm.nih.gov/18280844/ Sensitivity of the bacterial meningitis score in 889 children with bacterial meningitis]. ''J Pediatr''. 2008 Mar;152(3):378-82. doi: 10.1016/j.jpeds.2007.07.012. Epub 2007 Oct 22. PMID: 18280844.
 +
*Whelan H, Harmelink M, Chou E, Sallowm D, Khan N, Patil R, Sannagowdara K, Kim JH, Chen WL, Khalil S, Bajic I, Keval A, Greydanus D. [https://www.sciencedirect.com/science/article/pii/S001150291630102X?via%3Dihub Complex febrile seizures-A systematic review]. Dis Mon. 2017 Jan;63(1):5-23. doi: 10.1016/j.disamonth.2016.12.001. Epub 2017 Jan 12. PMID: 28089358.
 +
*Subcommittee on Febrile Seizures, American Academy of Pediatrics. [https://pediatrics.aappublications.org/content/pediatrics/127/2/389.full.pdf Neurodiagnostic evaluation of the child with a simple febrile seizure]. ''Pediatrics'', 127 (2) (2011), pp. 389-394
 +
* [[media:Seizure -4-30-2019.pdf|Pediatric Seizures 2019]] PowerPoint Presentation by Dr. Lindsey Morgan (SCH Neurology)
 
*[[Seizures RMT|Seizures RMT Guide]]
 
*[[Seizures RMT|Seizures RMT Guide]]
 +
* [https://www.seattlechildrens.org/pdf/seizure-pathway.pdf Seattle Children's Hospital Seizure Emergency Department Guideline]
 
* [[media:Seizure_evaluation_peds.pdf|Seizure Evaluation (Pediatrics) YKHC Clinical Guideline]]
 
* [[media:Seizure_evaluation_peds.pdf|Seizure Evaluation (Pediatrics) YKHC Clinical Guideline]]
 
* [[media:Seizure_treatment_peds.pdf|Seizure Treatment (Pediatrics) YKHC Clinical Guideline]]
 
* [[media:Seizure_treatment_peds.pdf|Seizure Treatment (Pediatrics) YKHC Clinical Guideline]]

Latest revision as of 21:24, 4 February 2021

Epidemiology of Epilepsy:

  • Incidence: averages ~150,000 or 48 per 100,000 people each year
  • Prevalence in US: 5-11.5 per 1,000
  • In 2015: 1.2% US population had active epilepsy
    • Alaska:7,200 (1,100 children, 6,100 adults)

Diagnosis:

  • Look for Causes:
    • history of epilepsy or seizure disorder
    • febrile/FIRES (Febrile infection-related epilepsy syndrome)
    • metabolic abnormalities (low or high Na, low Ca2+, low or high glucose, low Magnesium)
      • NOTE: Remember to check a glucose if a child presents with new onset seizure. If unable to obtain (glucose monitor not working), consider giving glucose gel. If requiring multiple antiseizure medication doses and good story of hypervolemic hyponatremia (infant given water or poorly mixed formula), consider giving a NS bolus before you are able to get a Na level.
    • Infection
    • trauma
    • Severe Breath Holding: Consider this etiology if the child was crying very hard, held his breath, turned red/purple (occasionally blue), and then passed out with seizure-like activity

Critical Times for Affected Patients:

  • Mortality rate associated with seizures lasting >30 minutes as high as 19%
  • Status Epilepticus (SE): Tonic-clonic (>5 min), Focal SE with impaired consciousness (>10 min), Absence SE (>10-15 min)
  • For all children at least 6months old or older who live in the village presenting with seizure activity, strongly consider dispensing an appropriate dose of Rectal Diastat upon discharge to the village. While village clinics are supposed to be stocked with midazolam, fosphenytoin, and phenobarbital; they may have used these medications and not had time to restock due to weather delay or recent use. The Rectal Diastat may be the only Antiseizure medication available in the village to treat your patient in status epilepticus.

Management:

Morbidity (Epilepsy or prolonged status epilepticus):

  • Focal neurologic deficits
  • Cognitive Impairment
  • Behavioral Problems
  • SUDEP (Sudden Unexpected Death in EPilepsy)
    • each year 1 in 4,500 children die (1 in 150 if seizures uncontrolled)
    • unclear if primary brain, cardiac, or respiratory
    • no data that anti-suffocation pillows prevent

Resources/References


YKHC Clinical Guidelines
Common/Unique Medical Diagnoses