pediatric emergency conference. speiser, et al. new england journal of medicine, 2003

Pediatric Emergency Conference

Speiser, et al. New England Journal of Medicine, 2003

Seizuresresult from rapid abnormal electrical

discharges from cerebral neuronspresents clinically as involuntary alterations

of consciousness or motor activityConsumption of oxygen, glucose, and

energy substrates (e.g, ATP, phosphocreatine) is significantly increased in cerebral tissue during seizures.

Optimal delivery of these metabolic substrates to cerebral tissue requires adequate cardiac output and intravascular fluid volume.

Pediatric, Status Epilepticus; emedicine 2008

Important points in the History The course of current seizure activity

◦ Time and nature of onset of seizure activity◦ Involvement of extremities or other body parts◦ Nature of movements (eg, eye movements, flexion,

extension, stiffening of extremities), including any focal movements and details of postictal neurologic deficit

◦ Incontinence◦ Cyanosis (perioral or facial)◦ Duration of seizure activity prior to medical attention◦ Mental status after cessation of seizure activity

Fever or intercurrent illnesses Prior history of seizures - If present, specify

medications, anticonvulsant use, and compliance.


Important points in the HistoryHead injury (recent and remote)CNS infection or disease (eg, meningitis,

neurocutaneous syndrome)Intoxication or toxic exposureOther CNS abnormality (eg, ventricular-

peritoneal shunt, prior CNS trauma)Birth history and developmental delay (eg,

anoxic encephalopathy, cerebral palsy)Other medical history (eg, acquired

immunodeficiency syndrome, systemic lupus erythematosus, type 1 diabetes mellitus)


Important points in the PE Signs of sepsis or meningitis

◦ Temperature more than 38.5°C; in patients younger than 2-3 months, more than 38.0°C

◦ Respiratory distress◦ Cyanosis◦ Poor peripheral perfusion◦ Bulging fontanelles in infant◦ Meningismus (in children >12-18 mo)◦ Presence of petechiae or purpura, herpetic vesicles

Evidence of head or other CNS injury◦ Bradycardia, tachypnea, and hypertension (Cushing triad for signs of

increased intracranial pressure)◦ Poor pupillary response◦ Asymmetry on neurologic examination◦ Abnormal posturing◦ Gross deformity or soft tissue injury to head

Hallmarks of neurocutaneous syndromes (e.g., port wine stain)


Monitoring of Vital FunctionsRespiratory rate, blood pressure,

cardiac rateObservation of seizure activitySkin bruises, petechiae or needle

marksPapilledema, retinal hemorrhagesOrganomegaly and abdominal

tenderness

Factors that lower Seizure ThresholdSleep deprivationHyperventilationPhotic stimulationInfectionMetabolic disturbancesHead traumaCerebral ischemiaKindling

Handbook of Neurosurgery by Greenberg

Status EpilepticusContinuous clinical or

electroencephalographic seizures lasting for at least 30 minutes or recurrent seizures without return of consciousness during interictal period: the series lasting for 30 minutes or more. It is a medical emergency.

Handbook of Medical & Surgical Emergencies, 6th edition

Clinical Classification of Status Epilepticus

Overt generalized convulsive status

epileptus

Subtle generalized convulsive

status epilepticus

Simple status epilepticus

Nonconvulsive status

epilepticus

Continuous convulsive activity and intermittent convulsive activity without regaining full consciousness

•Convulsive (tonic-clonic)•Tonic•Clonic•Myoclonic

Coma following generalized convulsive status epilepticus with or without motor activity

Consciousness preserved

•Simple motor status epilepticus•Sensory status epilepticus•Aphasic status epilepticus

Consciousness impaired; twilight or fugue state

•Petit mal status (absence status)•Complex partial status epilepticus

Handbook of Medical & Surgical Emergencies, 6th edition

Types of Status EpilepticusGeneralized Status

◦ Convulsive: generalized convulsive tonic-clonic status epilepticus (SE) is the most frequent type

◦ Absence◦ Secondarily generalized: accounts for ~75% of

generalized SE◦ Myoclonic◦ Atonic (drop attack): especially in Lennox-Gastaut

syndromePartial Status (usually related to anatomic

abnormality)◦ Simple (Epilepsy Partialis continuans)◦ Complex◦ Secondarily generalized


EtiologiesFebrile seizuresCerebrovascular accidentsCNS infection IdiopathicEpilepsySubtherapeutic antiepileptic drugElectrolyte imbalanceDrug intoxicationAlcohol withdrawalTraumatic brain injuryAnoxiaTumor


Neonates (first month of life)

Early childhood (<6 y)

Children and adolescents (>6 y)

Birth injury (eg, anoxia, hemorrhage) and congenital abnormalities

Birth injury Birth injury

Metabolic disorders (eg., hypoglycemia, hypocalcemia, hyponatremia) and inborn errors of metabolism (eg., lipidoses, amino acidurias)

Febrile convulsions (3 mo to 6 y) Trauma

Infection (eg, meningitis) Infection Infection

Metabolic disorders Epilepsy with inadequate drug levels

Trauma Cerebral degenerative disease

Neurocutaneous syndromes Tumor

Cerebral degenerative diseases Toxins

Tumors Idiopathic

Idiopathic


DIFFERENTIAL DIAGNOSIS

In children < 1year age75% acute cause

30% electrolyte disorders28% secondary to CNS

infection19% associated with fever


Prolonged seizures are associated with cerebral hypoxia, hypoglycemia, and hypercarbia and with concurrent and progressive lactic and respiratory acidosis.

When cerebral metabolic needs exceed available oxygen, glucose, and metabolic substrates (especially during status epilepticus), neuronal destruction can occur and may be irreversible.

Hypoxia, hypercarbia, hyperthermia, tachycardia, hypertension, hyperglycemia, hyperkalemia, and lactic acidosis result from massive sympathetic discharge.


Prolonged seizures

Duration of seizure

Life threatening

systemicchanges

DeathTemporary

systemicchanges

Werner, MD; GTC SE in Children; University of Kentucky Hospital

MortalityThe primary determinant of mortality

and morbidity of SE in children is its etiology

The greatest mortality and highest rate of neurological deficits occurs when SE is caused by an acute neurological condition (infection, trauma, stroke)

Mitchell WG. J Child Neurol 2002;17 Suppl 1:S36-43.

Mean duration of SE in patients without neurologic sequelae is 1.5hours.

Mortality is lowest among children (~6%)subtherapeutic AEDsunprovoked SE

Highest Mortalityelderly patientsSE due to anoxia or CVA


Etiopathogenesis

pediatric emergency conference. speiser, et al. new england journal of medicine, 2003

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