Overview. 5% of paeds a+endances to ED

Transcription

1 Seizures

2 Overview 5% of paeds a+endances to ED

3 Status Epilepticus generalised convulsions las7ng 30 minutes or longer or failed to regain consciousness between fits over 30 minutes

4 Why is SE important? 4% mortality Significant morbidity: Epilepsy Learning difficul7es Behavioural problems Motor deficits

5 Why is it important? Cerebral autoregula7on is impaired Compromises blood flow Vicious cycle of anaerobic metabolism and lac7c acidosis Neuronal cell oedema/ death Increased intracranial presssure à further reduced perfusion Systemic: Leucocytosis, acidosis, DIC, Rhabdomyolysis, cardiac dysfunc7on- pulmonary oedema

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7 Neonates Subtle Motor or behavioural or autonomic Hypoglycemia <2mmol/L Feeding difficul7es, sepsis or metabolic disorders 2 ml/kg of 10% Glucose iv NAI

8 Febrile seizures 6 months to 6 years Self- limi7ng <15 min 5% with status

9 CNS infection Febrile CSE Local an7bio7c policy

10 Epilepsy Not everyone with seizures has epilepsy h/o AED- compliance, change or withdrawal Poisoning Non- convulsive or par7al

11 Hx and examination Focused clinical history Simultaneously assessing/managing ABC Drug/allergy hx Directed examina7on: Meningism, rash, fever, trauma Thorough examina7on a]er stabilisa7on- infec7on screen, neuro, fundoscopy, etc

12 Mx Airway manoeuvres NP airway (cau7on: Head injury) Reduced LOC à intubate Simultaneous- iv or IO access/ samples VBG- glucose, electrolytes, mixed metabolic and resp acidosis Bedside BM

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15 Airway High-flow oxygen Don t ever forget glucose Advanced Life Support Group A charity dedicated to saving life by providing training 5 minutes after convulsion started Yes or can be established quickly Vascular Access? No S T E P 1 Lorazepam 0.1 mg/kg IV/IO Midazolam (buccal) 0.5 mg/kg or Diazepam (rectal) 0.5 mg/kg If seizure is continuing 10 mins after start of step 1 S T E P 2 Lorazepam 0.1 mg/kg IV/IO Call for senior help Prepare phenytoin If seizure is continuing 10 mins after the start of step 2 reconfirm it is an epileptic seizure S T E P 3 Senior help is now needed Seek anaesthetic/icu advice Phenytoin 20 mg/kg IV/IO over 20 min Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes If seizure is continuing 20 mins after the start of step 3 (start of infusion) an anaesthetist MUST be present S T E P 4 RSI with Thiopental (Thiopentone)

16 Airway High-flow oxygen Don t ever forget glucose Advanced Life Support Group A charity dedicated to saving life by providing training 5 minutes after convulsion started Yes or can be established quickly Vascular Access? No

17 Yes or can be established quickly Vascular Access? No S T E P 1 Lorazepam 0.1 mg/kg IV/IO Midazolam (buccal) 0.5 mg/kg or Diazepam (rectal) 0.5 mg/kg

18 Yes or can be established quickly Vascular Access? No S T E P 1 Lorazepam 0.1 mg/kg IV/IO Midazolam (buccal) 0.5 mg/kg or Diazepam (rectal) 0.5 mg/kg If seizure is continuing 10 mins after start of step 1 S T E P 2 Lorazepam 0.1 mg/kg IV/IO Call for senior help Prepare phenytoin Or Diazepam 0.25 mg/kg iv

19 If seizure is continuing 10 mins after start of step 1 S T E P 2 Lorazepam 0.1 mg/kg IV/IO Call for senior help Prepare phenytoin If seizure is continuing 10 mins after the start of step 2 reconfirm it is an epileptic seizure S T E P 3 Senior help is now needed Seek anaesthetic/icu advice Phenytoin 20 mg/kg IV/IO over 20 min Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes

20 Prepare phenytoin If seizure is continuing 10 mins after the start of step 2 reconfirm it is an epileptic seizure S T E P 3 Senior help is now needed Seek anaesthetic/icu advice Phenytoin 20 mg/kg IV/IO over 20 min Or if already on phenytoin give phenobarbitone 20 mg/kg IV/IO over 5 minutes If seizure is continuing 20 mins after the start of step 3 (start of infusion) an anaesthetist MUST be present S T E P 4 RSI with Thiopental (Thiopentone)

21 CSE Longer a fit con7nues, more difficult it can be to terminate More likely to intubate Think ahead and have essen7al drugs Senior anaesthe7c help sooner Phenytoin alternate: Phenobarbitone Leve7racetam Valproate

22 Intubation and sedation RSI- thiopentone Morphine and Midazolam infusion Short ac7ng relaxant D/w PICU Further seizures- further AED; midaz bolus; double M+M rate Reassess; review blood reports; CT; NGT Normothermia/carbia/glycaemia/30 headup

23 Further after I&V Seizure controlled and cause corrected Extubate or transfer d/w ter7ary centre Depending on age, cause, ward and medical cover Minimise delay of transfer

24 Summary Management is highly protocolised Early VBG and don t forget glucose Decisive and 7mely interven7on could prevent long- term injury.