Emergency managment of the pediatric patient with generalized convulsive status epilepticus Flashcards Preview

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Flashcards in Emergency managment of the pediatric patient with generalized convulsive status epilepticus Deck (34):
1

What is the definition of convulsive status epilepticus (CSE)?

1. Continuous generalized tonic-clonic seizure activity with loss of consciousness for longer than 30min

OR 2. >2 discrete seizures without a return to baseline mental status

2

What is "early" or "impending" status epilepticus?

Continuous or intermittent seizure lasting longer than 5min without full recovery of consciousness between seizures

3

What is the annual incidence of CSE?

10-73/100 000 children
135-156/100 000 children <2yo

4

What is the mortality of CSE?

2.7-8%

5

What is the overall morbidity (mainly newly diagnosed neurological disorders) of CSE?

10-20%

6

What are common acute symptomatic etiologies (17-52%) of CSE?

1. Acute CNS infection (bacterial meningitis, viral meningitis, or encephalitis)
2. Metabolic derangement (hypoglycemia, hyperglycemia, hyponatremia, hypocalcemia or anoxic injury)
3. Anti-epileptic drug noncompliance or withdrawal
4. Anti-epileptic drug overdose
5. Non-anti-epileptic drug overdose
6. Prolonged febrile convulsion (23-30%)

7

What are common remote etiologies (16-39%) of CSE?

1. Cerebral migrational disorders (lissencephaly or schizencephaly)
2. Cerebral dysgenesis
3. Perinatal HIE
4. Progressive neurodegenerative disorders

8

How common is idiopathic or cryptogenic CSE?

5-19%

9

What are the objectives for the acute management of CSE?

1. Maintenance of ABCs
2. Termination of seizure and prevention of recurrence
3. Diagnosis and initial therapy of life-threatening causes of CSE
4. Arrangement of appropriate referral for ongoing care or transport to a secondary or tertiary care centre
5. Management of refractory status epilepticus

10

When do ischemic and excitotoxic neuronal cell loss start to occur?

After 30 min of seizure

11

At what time are seizures at risk of continuing for at least 30min?

After 5-10min

12

What are pre-hospital management option for status epilepticus?

1. Lorazepam buccal/PR 0.1mg/kg (max 4mg)
2. Midazolam buccal 0.5mg/kg (max 10mg) OR intranasal 0.2mg/kg (max 5mg/nostril)
3. Diazepam PR 0.5mg/kg (max 20mg/dose)

13

What are the first and second line options for a seizing patient with IV access?

1. Lorazepam IV 0.1mg/kg (max 4mg)
2. Midazolam IV 0.1mg/kg (max 10mg)
3. Diazepam 0.3mg/kg (max 5mg <5yo or 10mg >5yo)
Repeat x1 within 5min

14

What are the first and second line options for a seizing patient without IV access?

1. Lorazepam buccal/PR 0.1mg/kg (max 4mg)
2. Midazolam buccal 0.5mg/kg (max 10mg) OR intranasal 0.2mg/kg (max 5mg/nostril)
3. Diazepam PR 0.5mg/kg (max 20mg/dose)
Repeat x 1 within 5min

15

What are the third line options for a seizing patient with IV access?

1. Fosphenytoin IV 20mg/kg in NS or D5W (max 1000mg) over 5-10min
2. Phenytoin IV 20mg/kg in NS over 20min (max 1000mg)
3. Phenobarbital 20mg/kg in NS or D5W over 20min (max 1000mg)

16

What are the fourth line options for a seizing patient with IV access?

Use phenobarbital if fosphenytoin/phenytoin already used OR
use fosphenytoin or phenytoin if phenobarbital already used

17

What are the third line options for a seizing patient WITHOUT IV access?

1. Fosphenytoin IM 20mg/kg (max 1000mg)
2. Paraldehyde PR 400mg/kg (0.4mL/kg/dose) max 10g (10mL) dilute 1:1 in oil
3. Phenytoin IO 20mg/kg in NS (max 1000mg)

18

What are the fourth line options for a seizing patient WITHOUT IV access?

Use paraldehyde as above if fosphenytoin/phenytoin used OR
use fosphenytoin or phenytoin if paraldehyde used already

19

What should be used for refractory status epilepticus?

1. RSI
2. Midazolam continuous infusion
3. Thiopental/Pentobarbital bolus, continuous infusion

20

When should hypoglycemia be treated?

<2.6mmol/L

21

What is the recommended management of hypoglycemia in CSE?

1. 2-4mL/kg of D25W IV
2. 5mL/kg D10W IV

22

What are the SE of benzodiazepines?

1. Respiratory depression
2. Hypotension
3. Sedation

23

What are the side effects of fosphenytoin?

1. Hypotension
2. Bradycardia
3. Arrhythmia

24

What are the side effects of phenytoin?

1. Hypotenstion
2. Bradycardia
3. Arrhythmia
4. "Purple glove" syndrome from extravasation

25

What are the SE of phenobarbital?

1. Respiratory depression
2. Hypotension
3. Sedation

26

What are the SE of paraldehyde?

1. Mucosal irritation

27

What other medication can be considered in CSE?

Pyridoxine (vitamin B6) 100mg IV, then 50mg IV/PO BID

28

What investigations should be considered in CSE?

1. Electrolytes
2. Glucose
3. CBC + diff
4. Cultures (if sepsis suspected)
5. Cap or art gas
6. Anticonvulsant levels
7. Urine and blood for tox screen
8. Serum Ca, BUN, Mg, liver enzymes, lactate, NH4
9. LP

29

What are reasons for head CT in the context of CSE?

1. history of trauma
2. evidence of ICP
3. focal neurological signs
4. unexplained LOC
5. suspicion of cerebral herniation

30

When should non-CSE be expected?

If LOC does not recover as expected post convulsion do EEG to exclude non-CSE

31

When should a child be referred to a secondary or tertiary care hospital?

1. Children without history of previous epilepsy or febrile seizures

32

When should children be transported to a PICU?

1. Unstable vital signs
2. Continuing CSE

33

What is the definition of refractory status epilepticus (RSE)?

1. CSE unresponsive to different anti-epileptic medications
2. Duration >30-60min

34

What are other medication options for RSE?

1. Propofol
2. Topiramate
3. Levetiracetam

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