Office Emergencies

Seizures: A Review

objectives5

2. Brief seizure review

3. Status epilepticus: the true emergency

4. Febrile seizures: not so bad

5. First unprovoked seizures: also, not so bad

1. Resuscitation basics

Objective #1

A kid is seizing in clinic. What do I

do?

ABC’s + D+ call for help

All Pre-hospital Pediatric Seizure Care Guidelines Follow This Sequence:

Initial Medical Care/Assessment

Protect Child From Injury

Vomiting and Aspiration Precautions

Head-tilt, chin liftJaw thrust

The Recovery Position

Objective #2

Wait, can you review seizure classifications

real quick?

Seizure ClassificationGeneralized Partial

Complex Simple Both hemispheres involved

+LOC

Types:- Tonic/clonic- Absence - Atonic (drop attacks)- Infantile spasms

Impaired consciousness

Motor/autonomic sx

May generalize

Types of symptoms: 1) Motor- head/eye deviation, jerking, stiffening2) Autonomic- pupil dilation, drooling, pallor, HR/RR changes3) Somatosensory- smells, alteration of perception

No impaired consciousness

Can involve motor, autonomic, somatosensory

May generalize

Clinical Presentations That Can Mimic Seizures

ApeaBreath Holding

DizzinessMyoclonus

PseudoseizuresRigors

SyncopeTics

Strokes

Objective #3

This kid’s seizures are not stopping. I’m freaking out.

Status Epilepticus

Life Threatening Emergency

Seizures that persist without interruption > 5 mins

Two or more sequential seizures without full recovery of consciousness between seizures

Millikan D et al. Emerg Med Clin North Am. 2009

Status Epilepticus

Occurs in kids with epilepsy 9-27% over time

Rapid termination of seizure activity protects against neuronal injury

Millikan D et al. Emerg Med Clin North Am. 2009

Riviello JJ et al. Neurology. 2006

Status Epilepticus:Types, Incidence, & Description

Prehospital Assessment

Assess ABCs +D x 2 (Dextrose, Disability)

Positioning (C-spine protection if trauma):Jaw thrust/head tilt chin lift

Recovery position

Nasal airway, if needed and available

Aspiration precautions

Oxygen, Suction

Prehospital Assessment

Obtain seizure history

How long was it? What did it look like?

History of previous seizures (PMHx, FHx)Current illness? Trauma/abuse?

Length of postictal phase

List of current medications

Include any antipyretics given (time and dose)

Do the parents have any anticonvulsant medications (rectal diazepam)?

Have the patients given any anticonvulsant medications (time and dose)?

Prehospital Assessment

Prehospital Management

If actively seizing >5 mins and parent has not given rectal diazepam, administer it

Document time and dose

Continue O2, suction

Follow BLS guidelines (BVM if inadequate oxygenation)

Call EMS to transfer to ED

Obtain IV/IO access if possible and does not delay definitive care

Objective #4

What do I do with febrile seizures?

What’s a Febrile Seizure?

Caused by increase in core body temp > 100.4F (38C)

Threshold of temp which may trigger seizures is unique to each child

Febrile Seizure Facts

Benign

Peak occurrence: between 6 months to 5 years of age

May be either simple or complex

Accompanied by fever (before, during, after) WITHOUT ANY:CNS infection

Metabolic disturbanceUnderlying structural brain abnormality

2 Types of Febrile Seizures

Simple Complex

Seizure lasting < 15 mins

Generalized

Occurs ONCE in a 24 hour period

Seizure lasting > 15 mins

Focal

Occurs MORE THAN ONCE in a 24 hour period

Prehospital Assessment

1) Assess ABCs +D x 2 (Dextrose, Disability)

2) Obtain seizure history:

How long was it? What did it look like?

History of previous seizures (PMHx, FHx)Current illness? Trauma/abuse?

Length of postictal phase

3) Get a list of current meds

Prehospital Management

Monitor ABCDs

Position with C-Spine protection (if trauma)

Treat fever or underlying source of infection

Observe and transfer to ED if necessary

Objective #5

This kid seized for the first time but looks great now. Do I really have to

call neurology?

First Unprovoked Seizure

First seizure that occurs WITHOUT an immediate precipitating event

Etiology Remote symptomatic:

Related to a pre-existing brain abnormality/insult

Cryptogenic/idiopathic: no known cause

Can present as a:Partial seizure

Generalized, tonic-clonic seizureTonic seizure

Prehospital Assessment

1) Assess ABCs +D x 2 (Dextrose, Disability)

2) Obtain seizure history:

How long was it? What did it look like?

History of previous seizures (PMHx, FHx)Current illness? Trauma/abuse?

Length of postictal phase

3) Get a list of current meds

Prehospital Assessment

Monitor ABCDs

Position with C-Spine protection (if trauma)

Observe and transfer to ED if necessary

Recurrence Risk After First Unprovoked Seizure

Majority of children will have few or no recurrences:approximately 10-20% will have additional seizures regardless of therapy

Predictors of recurrence include: Abnormal EEG

Underlying etiologyAbnormal neurologic exams

Remote symptomatic- recurrence risk over 2 years is > 50%Cryptogenic/idiopathic- recurrence risk over 2 years is 30-50%

Hirtz D et al. Neurology. 2003

Objective #1 Objective #2 Objective #3 Objective #4 Objective #5

Don’t Panic. ABCDs is your mantra.

Call for help.

If actively seizing or postictal place in recovery position.

If trauma suspected, place in C-collar and jaw thrust to ensure adequate airway

We quickly reviewed seizure classifications.

Remember, a lot of other conditions can mimic seizure activity. Verbal and physical stimulation won’t

interrupt a seizure.

Status epilepticus is a true medical emergency

ABCDs, oxygen, suction, recovery position Rectal diastat/IN versed

Call EMS

Simple febrile seizures need no further work up or evaluation besides treating underlying

cause for fever

Complex febrile seizures need further evaluation

First-time unprovoked seizures may or may not need immediate neurology consultation.

~10% of kids will have another seizure at some point

WRAP-UP