Pediatric_Neurologic_Emergencies

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Pediatric_Neurologic_Emergencies Powered By Docstoc
					pediatric neurologic
   emergencies

  may 2002 core rounds
contents
   seizures
    – approaches to
          febrile seizure
          new onset non-febrile seizure
          established seizure disorder with recurrence
          neonatal seizures
          status epilepticus
    – investigation, treatment, disposition
   headache
    – discussion (as little evidence to support)
          migraine treatment
          imaging indications
case 1
 2 year old
 parents “shaking episode” lasting “10 mins”
 EMS called - child no longer shaking
 V/S - BP 105/60 HR 100 RR 18 Sat N T39


   approach?
    – well looking child
          first event
          multiple events
    – sick looking child
case 2
   8 year old
   parents describe good history for tonic-clonic
    activity lasting 2 mins
   1st event
   post event confusion - improving
   in ED - V/S N, N sensorium, N neuro exam
   otherwise healthy, no meds, no allergies

   approach?
case 3
 16 year old
 known seizure disorder, on phenytoin
 typical seizure presenting complaint
 V/S N, neuro N, otherwise looks well


   approach?
case 4
   2 week old
   parents - “doesn’t look right”, “mouth opening and
    closing”
   one episode lasting 1 minute
   child not interested in feeding, sleepy
   V/S - BP 90/50 HR 130 RR 38 sat N T 37.8
   otherwise normal exam

   approach?
definitions
   febrile seizure – NIH defn - event of
    infancy/childhood, typically between age
    3mo and 5yrs, with no evidence intracranial
    infection or defined cause

   epilepsy - two or more seizures not
    provoked by a specific event such as fever,
    trauma, infection, or chemical change
definitions
   neonatal seizure – in first 28 days of life
    (typically first few days)

   status epilepticus
    – seizure lasting >30 mins
        NB rosen 5-10 mins

    – sequential seizures without regain LOC >30min
classification
   generalized
    – LOC
    – tonic, clonic, tonic-clonic, myoclonic, atonic, absence
   partial – focal onset
    – simple partial – no LOC
    – complex partial – LOC
    – partial secondarily generalized
   unclassified
etiology
 infectious
 metabolic
 traumatic
 toxic
 neoplastic
 epileptic
 other
differential diagnosis
 syncope
 breath holding
 sleep disorders (eg. narcolepsy)
 paroxysmal movement disorder
    – tics,tremors
 migraines
 psychogenic seizures
approach to febrile seizures
the numbers
   epidemiology
    – age 3mo – 5yrs
    – peak age 9-20 mo
    – 2-5% children will have before age 5
    – 25-40% will have family history
    – 80 – 97% simple
    – 3 - 20% complex
simple febrile seizure
 < 15 mins
 no focal features
 no greater than 1 episode in 24h
 neurologically and developmentally normal
complex febrile seizure
   >15 min
    – febrile epilepticus >30min or recurrent without
      regaining consciousness > 30min
 focal
 recurrence within 24h
what do parents want to
know?
   recurrence
    – risk recurrence 25-50%
    – risk recurrence after 2nd – 50%
    – most recurrences within 6-12 mo
           (20% within same febrile illness)
   risk of epilepsy
    – 2-3% (baseline 1%)
    – increased in
           family history of epilepsy
           abnormal developmental status
           complex febrile seizure
neonatal seizure
   brief and subtle
    – eye blinking
    – mouth/tongue movements
    – “bicycling” motion to limbs
 typically sz’s can’t be provoked/consoled
 autonomic changes
 EEG less predictable
neonatal seizure
   etiology
    – hypoxic-ischemic encephalopathy
          Presents within first day
    – congenital CNS anomalies
    – intracranial hemorrhage
    – electrolyte abnormalities – hypoglycemia and
      hypocalcemia
    – infections
    – drug withdrawal
    – pyrodoxine deficiency
status epilepticus
   definition
    – deizure lasting >30 mins
        NB Rosen 5-10 mins

    – sequential seizures without regain LOC >30min


 mortality in pediatric status epilepticus 4%
 morbidity may be as high as 30%
SE treatment considerations
 ABC’s
 brief directed Hx and Px


 glucose
 antibiotics/antivirals
    – if meningitis/encephalitis considered
SE treatment
   1st line anticonvulsants
    – IV
           lorazepam 0.1mg/kg
           diazepam 0.2 mg/kg
           midazolam 0.2 mg/kg
    – rectal diazepam
           2-5 yrs – 0.5 mg/kg
           6-11 yrs – 0.3 mg/kg
           >12 yrs – 0.2 mg/kg
    – IM, intranasal, buccal midazolam
SE treatment
   2nd line agents
    – phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min)
    – fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150
       mg/min)
   3rd line agents
    – phenobarbital 20mg/kg @ 100mg/min
    – repeat prn 5-10mg/kg
    – maximum 40 mg/kg or 1 gram
refractory SE treatment
   consider midazolam
    – 0.2 mg/kg bolus
    – then 1-10 mcg/kg/min infusion
   induce barbiturate coma
    – pentobarbital 5-15 mg/kg @ 25 mg/min
    – then 1-5 mg/kg/hour
   others
    –   valproic acid
    –   paraldehyde, chloral hydrate
    –   propofol, inhalational anesthesia, paralysis
    –   lidocaine
approach – stable post sz
   history
    – pre-seizure
           what was child doing when attack occurred
           precipitants – fever, trauma, poisoning, drug/med use
           aura
    – deizure
           what movements – incl. eyes
           how long
           LOC?
           consequences – resp distress, incontinence, injury
    – post seizure
           Post-ictal
approach to stable patient
   physical directed towards
    – systemic disease
    – infection
    – toxic exposure
    – focal neuro signs
laboratory
 blood glucose?
 electrolytes?
 magnesium, calcium?


 anything at all?
 what about first time seizures? recurrent?
laboratory
   yes if…
    –   neonatal
    –   abnormal mental status persistent
    –   diabetics, renal disease
    –   diuretic use
    –   dehydration
    –   malnourishment
laboratory
   septic work-up (CBC, BC, urine C+S, CXR, LP)
    – as indicated
            sick child
            < 12 - 18 mo


   therapeutic drug levels

   other
    –   ABG
    –   toxicologic screen
    –   TORCH, ammonia, amino acids in neonate
    –   CPK, lactate, prolactin – ?confirm seizure?
lumbar puncture
   patients at greatest risk for meningitis
    –   under 18 months of age
    –   seizure in the ED
    –   focal or prolonged seizure
    –   seen a physician within the past 48 hours
   other indications
    – concern about follow-up
    – prior treatment with antibiotics
   The American Academy of Pediatrics
            “strongly consider” in infants under 12 months of age with a
             first febrile seizure
neuroimaging
   WHO? which patients?

   WHAT? CT vs. MRI
    – ultrasound in neonates


   WHEN? emergent vs. elective
ACEP guidelines - >6 yo
       consensus indication for non-contrast CT
       first time seizure patients
    –     if suspect structural lesion
    –     partial onset seizure
    –     age > 40
    –     no other identified cause
       recurrent seizure patients
    –     change in pattern
    –     prolonged post-ictal period
    –     worsening mental status
neuroimaging
   predictors of abnormal findings of computed tomography of the head in
    pediatric patients presenting with seizures
   Warden CR - Ann Emerg Med - 01-Apr-1997; 29(4): 518-23
     – retrospective case series
     – predicts CT scan results normal if
            no underlying high-risk condition
               – malignancy, NCT, recent CHI, or recent CSF shunt revision
            older than 6 months
            sustained a seizure of 15 minutes or less
            no new-onset focal neurologic deficit
     – not prospectively validated
emergent EEG?
 not generally available on emergent basis
 but consider in..
    – persistent altered mental status (?non
      convulsive status epilepticus)
    – paralyzed patients
    – pharmacologic coma
disposition
   can be discharged home if
    – single seizure
    – stable, returning to baseline neuro status
    – no underlying condition/cause requiring
      treatment in hospital
    – arranged follow-up
EEG – 1st non-febrile seizure
   follow-up EEG
    – within 24h
          Lancet 1998;352:1007-11
          improved pick-up 51% vs 34%
          ? how soon do we get ours ?
    – inter-ictal EEG’s often normal
          neuro may do sleep deprivation study (provocation)
    – absence epilepsy and infantile spasms are invariably
      associated with an abnormal EEG
    – spike and wave 3HZ
idiopathic seizure
   recurrence risk stratification
    – normal EEG – 25%
    – abN EEG – 60%
    – 2nd seizure – 75%
neuroimaging
   MRI superior

   not emergently available

   ?defer imaging until follow-up MRI
    available in low risk patients?
treatment
 correct underlying pathology, if any
 antipyretics ineffective in febrile seizure
 anti-epileptic choice often trial and error
           no anti-epileptic 100% effective
           febrile seizure – diazepam, phenobarbital, valproic acid
              – Currently AAP does not recommend
           neonatal - phenobarbital
           generalized TC – phenytoin, phenobarbital, carbamazepine,
            valproic acid, primidone
           absence – ethosuximide, valproic acid
           new anti-epileptics – felbamate, gabapentin, lamotrigine,
            topiramate, tiagabine, vigabatrine
   in consultation with neurologist
pediatric headache
case 5
 14 year old
 mother’s chief complaint - “having headaches all
  the time, getting worse, this is not normal!!” etc.
  etc……..
 V/S N
 looks in discomfort but otherwise well


   approach?
    – treatment
    – imaging?
classification
   classify based on temporal pattern

   acute headaches
    – any febrile illness, sinus/dental infection, intracranial
      infection/bleed (AVM,SAH,trauma)
 acute recurrent
 chronic progressive
 chronic non-progressive
    – tension, psychogenic, post-traumatic, ocular refractive
      error
acute recurrent headache
   migraine

   other
    – cluster headache – typically >10 yo
    – sinusitis
    – vascular malformation
migraine - terminology
   classic migraine
    – biphasic
          neuro aura
         headache, N/V, anorexia, photophobia

    – either unilateral (older) / bilateral(younger) or both
   common migraine
    – malaise, dizziness, N/V, feels and looks sick
    – unilateral/bilateral
   migraine equivalent/”complicated migraine”
    – transient neuro deficits
    – +/- headache
   migraine variants
    – Cyclic N/V, abdo pain
    – BPV
migraine treatment
 very little supporting evidence for pharmacologic
  treatment in children compared to adults
 classes of medication
    – acetaminophen
    – NSAIDS
    – phenothiazines (dopamine antagonists)
    – dihydroergotamine
    – triptans
the simple stuff
 acetaminophen 15 mg/kg PO 30mg/kg PR
 ibuprofen 10 mg/kg PO

   Hamalainen ML Ibuprofen or acetaminophen for the acute treatment of
    migraine in children: A double-blind, randomized, placebo-controlled,
    crossover study
    Neurology 48:103-107, 1997
     – N = 88 age 4-16
     – relief at 2 hours
          acetaminophen 54%

          ibuprofen 68%
other NSAIDS
   naproxen 5-7 mg/kg PO
    – no pediatric evidence
   ketorolac IV 0.5 mg/kg (max 30mg dose)
    – not studied in pediatric migraine
    – not approved <16 yo
    –   Houck CS – Safety of intravenous ketorolac in children and cost savings with a unit
        dosing system. J Pediatr - 01-Aug-1996; 129(2): 292-6
           1747 children

           0.2% hypersensitivity

           0.1% renal complications (in patients with renal disease)

           0.05% gi bleed
dihydroergotamine
 not approved
 ?dose – 0.1 – 0.5 mg IV
 not studied in emergency population

   Linder SL – Treatment of childhood migraine with dihydroergotamine
    mesylate Headache - 1994 Nov-Dec; 34(10): 578-80
     – N = 30
     – inpatient protocol
     – IV DHE and PO metoclopramide – average 5 doses!
     – 80% response
phenothiazines
   again no studies

 metoclopramide 1-2 mg/kg IV (max 10mg)
 prochloperazine 0.1 – 0.15 mg/kg
  IV/IM/PO/PR (max 10mg)

   children may be more susceptible to EPS
    – ? pre-treat with benadryl
triptans
 mostly studied in adolescent groups
 sumitriptan subcutaneous 0.06mg/kg
    – Linder S: Subcutaneous sumatriptan in the clinical setting: The first 50
      consecutive patients with acute migraine in a pediatric neurology office
      practice. Headache 36:419–422, 1996
    – N = 50 age 6-18
    – 78% effective at 2 hours
    – 6% recurrence

   sumitriptan intranasal
    – long term treatment studies done
    – no emergent studies
   triptans PO
    – studies plagued by high placebo response
chronic progressive headache
   least common presentation

   most worrisome for increased ICP
    – pseudotumor cerebri
    – space occupying lesion
imaging indications? discuss
   lack of evidence to help
    – small studies lack power to guide decision
      making


   MRI preferred in non-urgent indication
    imaging indications? discuss
   classically based on historical and physical
    –   sudden severe headache
    –   rapid increase over days - weeks
    –   chronic progressive
    –   suggestive of increased ICP
            severe nocturnal headache (wakes or upon waking), changes in
             pain with position, coughing
    – following head trauma
    – persistent neuro findings
            ? include migraine equivalents ?
    – growth abnormality
    – age (? <3 ?)