5/23/14. Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments

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1 Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments Andi Marmor, MD, MSEd Associate Professor, Pediatrics University of California, San Francisco Tesla is a previously healthy 16 mo girl BIB ambulance after she had a seizure Fell to the ground while playing and became stiff and non- responsive, eyes rolled back, for 30 seconds 911 called No apnea or focal movements noted Sleepy but responsive in ambulance, T = 37.9 Febrile to 39.0, VS otherwise WNL Neuro: Moving all extremities, fussy but consolable by father Initially sleepy but becoming more and more alert as you observe her No source for fever is apparent on history/pe 1

A. Obtain blood, urine and CSF cultures B. Admit for neurologic evaluation C. Obtain a head CT or MRI D. Obtain a stat EEG E. Discharge when at neurologic baseline Etiology: NOT fever! Cytokines!

HHV-6: Roseola NO: Rates of SBI in SFS similar to age- matched febrile children Meningitis?

2 A. Obtain blood, urine and CSF cultures B. Admit for neurologic evaluation C. Obtain a head CT or MRI D. Obtain a stat EEG E. Discharge when at neurologic baseline Etiology: NOT fever! Cytokines! Simple Febrile Seizure Short, generalized, isolated Generally considered benign Complex Febrile Seizure Longer OR focal OR recurrent May be more concerning? HHV-6: Roseola NO: Rates of SBI in SFS similar to age- matched febrile children Meningitis? No cases of meningitis in the absence of focal signs/symptoms in series of SFS/CFS However, meningitis can present with fever and seizure. Failure to return to normal MS/Focal neuro exam Febrile convulsive status Kimia, 2010; Fletcher 2013 Tesla comes back within 24 hours with another short, generalized seizure Now what would you do? Even children with CFS are at very low risk for SBI/meningitis LP can be done in select children with concerning features Febrile status, focal/abnormal neuro exam, recent antibiotics Kimia, 2010; Fletcher

5/23/14 EEG: Not useful in predicting recurrence or epilepsy, even in complex febrile

abnormality Identify and treat source for fever, by age Further workup based on H and P

Recent antibiotics, several days of fever before sz Focal seizure or recurrent complex

Obtain blood, urine and CSF cultures Admit for neurologic evaluation Obtain a head CT or MRI

3 5/23/14 EEG: Not useful in predicting recurrence or epilepsy, even in complex febrile seizures Anticonvulsants/antipyretics : do not alter course Conﬁrm child has no neurologic abnormality Identify and treat source for fever, by age Further workup based on H and P Consider LP for Consider referral to neuro for LP for convulsive status, abnormal neuro exam Recent antibiotics, several days of fever before sz Focal seizure or recurrent complex seizure A. B. C. D. E. Obtain blood, urine and CSF cultures Admit for neurologic evaluation Obtain a head CT or MRI Obtain a stat EEG Discharge when at neurologic baseline Recurrence: 10-50% Younger age, family history, complex seizure, lower temp Treat fevers appropriately for comfort only 3

4 Leaf is a 2 yo boy BIB ambulance after a generalized, tonic clonic seizure Given rectal diazepam seizure has ceased No prior seizures, developmentally normal Deny trauma, recent illness, travel, change in diet. He is afebrile, sleepy but arousable, improving Pushes you away purposefully and symmetrically, and knows his name and age A. Head CT B. Head MRI C. Complete H and P D. CBC and electrolytes E. Lumbar puncture Yield of imaging in children with a first- time afebrile seizure is very low 8% in one study (Sharma, 2003), with < 1% requiring immediate management Findings requiring intervention can be predicted by Predisposing factors (trauma, bleeding disorder) Age < 6 months Persistent neurologic abnormality A. Head CT B. Head MRI C. Complete H and P D. CBC and electrolytes E. Lumbar puncture 4

Neuroimaging, screening labs and/or lumbar puncture should not be routinely performed Consider imaging in the ED (CT or MRI) if History concerning for IC abnormality Persistent neurologic abnormality

5 Neuroimaging, screening labs and/or lumbar puncture should not be routinely performed Consider imaging in the ED (CT or MRI) if History concerning for IC abnormality Persistent neurologic abnormality < 6 mo of age Schedule pediatric/neurology follow up May include EEG, MRI if indicated (eg: focal seizure, < 3 years of age) Your resident calls you back in because Leaf has started to seize again The seizure is generalized, and he is breathing on his own VS: HR 150, RR 30, BP 110/75 You are concerned that Leaf is now in status epilepticus The RN mentions that the IV is not flushing Hirtz, 2000 A. IV lorazepam B. IM lorazepam C. IM midazolam D. Rectal diazepam E. Buccal midazolam If IV access: IV lorazepam (0.1mg/kg) quickest onset/ preferred treatment for all age groups Non- IV options: Buccal midazolam (0.5mg/kg): fastest option if time for IV access included Intranasal midazolam/lorazepam: requires atomizer Both superior to rectal/iv diazepam in RCT s 5

A. IV lorazepam B. IM lorazepam C. IM midazolam D.

Buccal midazolam Using highest concentration

Administer between cheek and teeth Half on each

fentanyl for painful procedures as well!

an IV: buccal midazolam Other options: Intranasal

6 A. IV lorazepam B. IM lorazepam C. IM midazolam D. Rectal diazepam E. Buccal midazolam Using highest concentration solution (5mg/ml) 1ml syringe without needle Administer between cheek and teeth Half on each side ½ in each nostril Must use atomizer Great for fentanyl for painful procedures as well! If you have an IV: IV lorazepam If you don t have an IV: buccal midazolam Other options: Intranasal lorazepam or midazolam After 2 doses of benzo, start fosphenytoin (unless < 1 mo) IV infusion or IM 6

5/23/14 Febrile Seizures: No additional studies needed for SFS or CFS if neuro

previous antibiotic Nikola Tesla treatment, seizure late in illness Afebrile

Treat pediatric status epilepticus with IV lorazepam or buccal midazolam x2 Then

7 5/23/14 Febrile Seizures: No additional studies needed for SFS or CFS if neuro exam improving at 30 min and normal at 1 hour Consider LP if: < 12 mo AND previous antibiotic Nikola Tesla treatment, seizure late in illness Afebrile Seizures: Imaging rarely indicated, if normal exam and no predisposing factors Treat pediatric status epilepticus with IV lorazepam or buccal midazolam x2 Then fosphenytoin LEAF (Leading, Environmentally friendly, Affordable, Family car) Tesla Roadster 7

Management of Complex Febrile Seizures

Management of Complex Febrile Seizures An 13 month old girl presents to the ED after having a shaking episode at home. Mom describes shaking of both arms and legs, lasting 20 minutes. The child has no