APLS > The Convulsing Child > Flashcards

The Convulsing Child Flashcards

(21 cards)

Study These Flashcards
1
Q

Define generalised CSE (convulsive status epilepticus).

A

Generalised CSE (Convulsive Status Epilepticus)

Generalised Convulsion

Lasting 30 mins or longer

OR

Frequent successive convulsions in a 30 min period

WITH NO RECOVERY of consciousness IN BETWEEN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

When do you start treatment in generalised CSE and why at this time?

A

After a seizure has lasted 5 mins or more -

because they may not stop spontaneously.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Name common causes of convulsions in children.

A

CAUSES OF CONVULSIONS

  • Epilepsy (1-5% will have CSE)
  • Febrile convulsions / fever (<6 yo) – 5% present w/ CSE
  • Meningitis/ encephalitis
  • Hypoxia
  • Metabolic abnormalities
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are some of the complications of prolonged convulsions?

A
  • General
    • hyperthermia
  • Resp
    • airway obstruction
    • hypoxia
    • aspiration of vomit
  • CVS
    • cardiac arrhythmias
    • hypertension
    • pulm. oedema
    • DIC
  • Renal
    • myoglobinuria
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the mortality rate status epilepticus in children?

A

4-6%

Lower than adults

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Name some of the adverse neurological outcomes of generalised CSE.

What is their incidence?

A

ADVERSE NEUROLOGICAL OUTCOMES:

  • Epilepsy (persistent)
  • Motor deficits
  • Learning/ Behavioural difficulties

INCIDENCE:

< 1 year = 29% (~1/3)

> 3 years = 6%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Describe the pathophysiology of prolonged convulsions.

A
  1. generalised convulsion
  2. cerebral metabolic rate increases x 3
  3. Loss of cerebral arterial regulation AND
  4. Increased sympathetic activity
    1. release of catecholamines
    2. peripheral vasoconstriction
    3. increased Systemic BP
  5. Increase in CBF (to provide oxygen and energy)
  6. Convulsions continue
  7. Systemic BP falls
  8. CBF reduces
  9. lactic acid accumulation
  10. Cell death
  11. Cerebral oedema
  12. Raised ICP
  13. Worsening cerebral perfusion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Describe the primary assessment and resuscitation of the child with convulsions.

A
  • A
    • airway opening manoeuvres
    • adjuncts
    • I+V
  • B
    • 100% O2 non-rebreather
    • BVM or I+V if inadequate resp effort
    • RECOVERY POSITION (if satisfactory breathing) - minimise risk of aspiration
    • stridor? grunting? –> consider raised ICP
    • reassess sats in RA frequently or measure ETCO2 to assess for hypoventilation caused by benzos/ barbiturates (may be masked if sats normal with cont O2 Tx)
  • C
    • HR + BP
      • bradycardia + hypertension = raised ICP
      • hypertensive crisis may be a cause of the convulsion, but usually hypertension is the result of convulsion
      • reassess frequently as benzos + barbiturates can cause hypotension
    • IV/ IO
    • Ix
      • baseline + CRP + Ca
      • BCx + meningococcal/ streptococcal PCR
      • Glucose (grey)
      • Lithium heparin (green) for freezing if new hypoG
      • Gas
    • Fluids
      • Bolus 20 ml/kg or 10ml/kg (trauma, raised ICP, cardiac pt, increased ADH secretion)
      • Na
        • aim 135-145
        • avoid hypoNa - use normal saline or add extra to fluids
    • IVAB + antiviral + dex
      • cefotaxime or ceftriaxone (sepsis / meningitis/ encephalitis)
      • erythromycin (mycoplasma meningoencephalitis)
      • aciclovir (herpes meningoencephalitis)
      • dexamethasone - in suspected/ confirmed bac. meningitis, within 4-12 hours post ABx.
        • > 3 months
        • reduces hearing loss + other longterm sequalae
        • 150 mcg/kg (max 10 mg)
      • **if suspected high ICP –> DO NOT DO LP - risk of coning and death**
      • **Normal fundi/CT does not exclude acutely raised ICP**
      • **early IVAB + antiviral is critical**
  • D
    • GCS/ AVPU
    • Pupils & reactivity
    • TONE/ POSTURE/ REFLEXES - ? lateralising signs –> I+V/ URGENT CT
    • Intracranial HTN signs –> 3% saline or 20% mannitol, head in-line + 20 degrees up, catheterise, dex if SOL, PCO2 4.5 - 5.5
    • Meningitic signs (consider variability in signs < 3 yo + > 4yo) –> IVAB + antiviral + dex
    • Consider
      • dystonic rxn? (drug-induced)
      • psychogenic / pseudo-epileptic seizure?
  • E
    • Temperature
      • Fever - treat with paracetamol/ PR diclofenac
        • infection
        • poisoning e.g. ecstacy, cocaine, aspirin
      • Hypothermia
        • poisoning e.g. barbiturates, ethanol
    • Purpuric Rash
      • meningococcal/ streptococcal sepsis
    • Bruising
      • NAI
    • Insert NGT /OGT & aspirate gastric contents
  • G
    • DON’T EVER FORGET GLUCOSE
    • Treat hypoglycaemia: GLU < 3 mmol/L
      • 2 ml/kg 10% GLUCOSE
      • –> maintenance w/ 5% GLUCOSE or 10% (infants) - rebound hypoglycaemia
    • NB hyperglycaemia may be stress induced
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What questions should be asked in the history for a convulsing child?

A

Child’s health and activity overthe previous 24 hours.

  • PC/ HPC - any trauma?
  • fever/ headache/ neck stiffness/ phophobia/ vomiting/ poor feeding/ irritable/ high pitched cry/ drowsiness/ cyanotic/ apnoeic attacks?
  • D&V? Abdo pain? Dysuria?
  • E+D? UO/ nappies?
  • PMH incl. epilepsy, diabetes, adrenal insufficiency
  • medications, allergies, food - last meal?
  • possible poison ingestion?
  • birth history
  • social history
  • FHx epilepsy/ febrile convulsions?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Describe the emergency management of convulsions.

A

ABCDEFG!!

FOLLOW INDIVIDUAL PROTOCOL IF AVAILABLE.

FOR INFANTS + CHILDREN (NOT NEONATES).

  1. LORAZEPAM or MIDAZOLAM/ DIAZEPAM
    • ​​5 mins after convulsion started
  2. LORAZEPAM
    • ​​10 mins after STEP 1 STARTED
  3. +/- PARALDEHYDE
  4. PHENYTOIN or PHENOBARBITONE
    • ​​10 mins after STEP 2 STARTED
  5. RSI - THIOPENTONE
    • 20 mins after infusion started IN STEP 4
  1. LORAZEPAM or MIDAZOLAM/ DIAZEPAM
    • ​​Lorazepam – if access established quickly
      • ​IV/ IO
      • 0.1 mg/kg
      • max 4 mg
    • Midazolam (buccal)
      • 0.5 mg/kg
    • Diazepam (rectal)
      • 0.5 mg/kg
  2. LORAZEPAM
    • ​​as above
    • if still fitting
    • if 2nd dose is needed - call CONSULTANT + PICU/ CATS/ anaesthetics (may need I+V + transfer)
    • majority of children - steps 1 + 2 will terminate
    • DO NOT GIVE > 2 X BENZO
  3. +/- PARALDEHYDE (rectal)
    • ​​PR
    • Optional
    • 0.4 ML/ kg
    • mixed with oil OR normal saline - 50:50 => 0.8 ml/ kg of the mixture
    • max per dose 20 ml
    • NB NOT arachis oil (children w/ peanut allergy may react)
    • whilst preparing/ infusing meds in the next step
    • DO NOT DELAY phenytoin/ phenobarbitone
  4. PHENYTOIN or PHENOBARBITONE
    • ​​Phenytoin
      • ONLY if not on phenytoin already
      • IV/ IO
      • 20 mg/ kg (max 300 mg)
      • over 20 mins (infusion rate no greater than 1 mg/ kg/ min)
      • make up in normal saline to a max concentration of 10 mg in 1 ml
      • give the full dose once started - anticonvulsant effect up to 24 hrs
      • ECG and BP monitoring (dysrhythmias + Hypotension)
    • Phenobarbitone
      • if on phenytoin
      • IV/ IO
      • 20 mg/ kg
      • over 20 mins
    • Other alternatives - on specialist/ senior advice:
      • IV levetiracetam (keppra)
      • IV sodium valproate
  5. RSI - THIOPENTONE (thiopental sodium) + short acting paralysing agent​
    • 4-8 mg/kg IV/ IO
    • general anaesthetic
    • no analgesic effect
    • marked cardioresp depression
    • alkaline solution - irritation if leak into S/C tissues
    • alternative = midazolam 0.1 mg/ kg/ hr
      • increased in steps of 0.1 mg/kg/hr
      • max 1 mg/ kg/ hr
    • +/- trial pyridoxine
      • < 3 yo
      • chronic, active epilepsy
    • get advice of neurologist
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Which has a longer duration of action

  • Midazolam?
  • Lorazepam?
A

Lorazepam: 12-24 hrs + less resp depression.

Midazolam: < 1 hr

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Can midazolam/ diazepam be used IV?

A

Yes, in places where lorazepam IV not available.

  • Midazolam 0.1 mg/kg IV/IO (same as lorazepam)
  • Diazepam 0.25 mg/kg IV/IO
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the benefits/ drawbacks of midazolam for terminating CSE?

A

Benefits:

  • takes effect within minutes
  • can be given IV/ IO / IM/ / buccal/ nasal
  • buccal and nasal = 2 x more effective than rectal diazepam (USE MIDAZOLAM > DIAZEPAM)

Drawbacks:

  • shorter lasting effect (<1 hr) Vs. 12-24 hrs for lorazepam
  • depresses respiration (5% of pts) - but short lived and easily managed with BVM ventilation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the benefits and drawbacks of paraldehyde?

A

PARALDEHYDE

Benefits:

  • Little respiratory depression
  • effect lasts 2-4 hrs

Drawbacks:

  • 10-15 mins to act
  • can cause rectal irritation
  • not possible to use in liver disease
  • can not be used IM - sterile abscess formation
  • can not be left standing in syringe for more than a few mins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Does phenytoin have a depressant effect on respiration?

A

A little.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is cerebral function analysis monitoring?

Study These Flashcards
A

Continuous brain activity bedside monitoring. Not the same as a formal EEG. Its role in assessing seizure activity is still unclear. EEG and clinical features preferred.

17
Q

Is hypertension common in children?

18
Q

Describe the most common cause of hypertension in children.

Study These Flashcards
A

CAUSES OF HYPERTENSION

  1. Renal disorders
    • dysplastic kidneys
    • reflux nephropathy
    • glomerulonephritis
  2. Coarctation of the aorta
19
Q

How may chidlren with hypertension present and why?

Study These Flashcards
A

Hypertension in children can present with diverse symptoms because BP not routinely measured in healthy children.

Neurological symptoms (raised ICP) more common than in adults:

  • severe headache
  • +/- vomiting
  • convulsions
  • coma
  • facial palsy
  • hemiplegia

Cardioresp presentations in babies:

  • apnoea
  • cardiac failure
20
Q

What guidelines should be followed to get an accurate BP measurement?

Study These Flashcards
A

BP measurement

  • always use the biggest cuff that will fit comfortably on the upper arm
  • a cuff that is too small will giev an erroneously high reading
  • systolic BP more reliable than diastolic because 4th korotkoff sound may be audible down to 0 / not heard
  • if electronic recording unexpected then recheck manually
  • check when child calm as pain/ screaming will cause raised BP
  • repeat any BP that is > 95th centile for age - if persistenly high will require treatment
21
Q

Describe the emergency Mx of hypetension.

Study These Flashcards
A

HYPERTENSION

  • Resuscitation
    • Stabilise ABC
    • Stabilisie D
      • manage seizures
      • manage ICP
  • Discuss hypertension with paeds renal / cardio/ ICU - will require PICU admission
  • Reduce BP over 24 - 48 hrs
    • reducing BP too quickly causes neuro damage including infarction of the optic nerve heads
    • 1/3 of the reduction in the first 8 hours
    • aim to bring down to 95th centile for age or height
    • titratable infusion of antihypertensive drug
  • Monitoring
    • BP
    • Visual acuity & Pupils (in the event of deterioration - lower dose of antihypertensive + use fluids)
    • renal function including UO
  • Drugs: - ALWAYS HAVE IV + MONITORING IN PLACE BEFORE GIVING!
    • labetalol
      • a & b - blocker
      • NOT in fluid overload/ acute heart failure
    • sodium nitroprusside
      • vasodilator
      • protect from light (degrades)
      • monitor cyanide levels
    • nifedipine
      • bolus => difficult to control BP drop
      • sublingual/ bite the capsule and swallow (better)
APLS
flashcards
Decks in class (25)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions