Outline. What is a seizure? What is epilepsy? Updates in Seizure Management Terminology, Triage & Treatment

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1 Outline Updates in Seizure Management Terminology, Triage & Treatment Joseph Sullivan, MD! Terminology! Videos of different types of seizures! Diagnostic evaluation! Treatment options! Acute! Maintenance What is a seizure? What is epilepsy? Sudden surge of electrical activity in the brain! This affects how a person feels or acts for a period of time! up to 5% of people will have a seizure at some point in their life At least 2 unprovoked seizures >24h apart! One unprovoked seizure and a probability of further seizures similar to that (60%) after 2 unprovoked seizures! diagnosis of an epilepsy syndrome Fisher RS, Epilepsia April 2014

2 Seizure Types Generalized-start on both sides of the brain! Focal-start in a specific area of the brain! Dyscognitive! Secondarily generalized-start out in a specific area but then spread! Semiology-constellation of events as a seizure evolves All seizures do not look the same! May be very subtle or very obvious! Depends on the area of the brain they originate from Focal w/secondary Generalization Videos

3 Focal dyscognitive Focal motor Frontal Tonic

4 Role of the! Pediatric Hospitalist Known Epilepsy Change from baseline seizure frequency/severity Guide acute treatment! Determine admission vs. no admission! Determine diagnostic work-up! New seizures vs. known epilepsy! Provide anticipatory guidance Assess need for admission based on general medical assessment Cover with bridging benzodiazepine Yes Illness? No Missed meds? Yes Review dosages, compliance No Check levels Consult with outpt neurologist Drug Levels Reasons to check levels Monitor compliance Document what level is not effective Can the medication be safely increased? Newer meds have longer turnaround time, but wider therapeutic windows. Better seizure management Not true AED levels Child on phenobarbital, phenytoin, carbamazepine, or valproic acid- Check level Child on one of the newer AED s levels check level if at the upper end of the weight based guidelines or if child is having tolerability issues.

5 New onset seizures Different situation! Diagnose conditions requiring URGENT intervention! Infection! Was it truly a seizure? Physical exam Normal Reassurance Outpt EEG Child neuro FU New seizures Focal exam findings not resolving Abnormal Abnormal mental status CONCERN FOR SUBCLINICAL SEIZURES? Intracranial process! Counsel families! Rescue medications at home Neuroimaging Admit LP Neuroimaging EEG Reasons to order neuroimaging in the ED/inpatient ward? Diagnose an underlying condition that requires immediate intervention. Hemorrhage Stroke Cerebral Abscess Tumor with resultant hydrocephalus Abnormal Imaging Scenarios Must know prior to discharge New bleed, abscess Good to know within 2-4 weeks Tumor Whenever Malformation of cortical development, remote encephalomalacia

6 Who to image High risk groups 500 children with a first non-febrile seizure 475 imaged in the ER 8% with clinically significant abnormalities 3/475 had findings needed immediate intervention 1 shunt failure 1 increased intra-cranial pressure after head trauma 1 with new-onset infantile spasms and a neoplasm High-risk groups to image in the ER Known bleeding or clotting disorders Known hx of malignancy HIV infection Closed head injury Less than 33 months with a focal seizure Sharma et al. Pediatrics 2003;111:1-5 Sharma et al. Pediatrics 2003;111:1-5 Who was missed Was it truly a seizure? New seizures Age History Physical Exam Diagnosis Management 2 mos 6 min seizure 3 y Status epilepticus Abnl mental status Abnl mental status 9 y 4 min seizure Normal 10 y 10 min seizure New Right hemiparesis 12 y 5 min seizure Normal 16 y 4 seizures Hypertension Subdural hematoma Anoxic brain injury 5 mm arachnoid cyst Benign frontal lobe tumor Grey matter heterotopia Hypertensive encephalopathy Child abuse eval, no surgery ICU admit, pt died AED started Resection 6 wk later AED started Anti-HTN and AED started Physical exam Normal Reassurance Outpt EEG Child neuro FU Focal exam findings not resolving Neuroimaging Abnormal Admit Abnormal mental status LP Neuroimaging CONCERN FOR SUBCLINICAL SEIZURES? EEG Sharma et al. Pediatrics 2003;111:1-5

7 Emergent EEG indication? Evaluate for sub-clinical/non-convulsive status Patient not returning to baseline as would be expected Presence of lip smacking, subtle clonic activity Emergent EEG is indicated Abortive agents Diastat (rectal diazepam) is the most convenient for home! Buccal or intranasal midazolam great for in hospital and home! Not all pharmacies will dispense Most common scenario Seizure/s self resolve! Child recovers and has normal exam! Overall 40% recurrence risk! Rarely treat with daily AED after first seizure Diastat

8 Intranasal midazolam Dispense IV multidose vial (5mg/ml)! Nasal atomizer! Dose is 0.1mg/kg PER nostril, max 5 mg per nostril! If no atomizer use buccal route! 0.5 mg/kg buccal space, max 10 mg Seizures to Status Isolated Seizures! Prodromal Stage (frequent seizures)! Incipient SE vs Single Seizure (<5 mins)! Early SE or Impending SE (5-30 mins)! Established SE (30-60 mins)! Refractory SE (>60 mins, not terminated by 2 meds! Malignant SE (anesthetics fail to terminate SE Treatment Goals Balance of morbidity of treatments vs. ongoing status! Avoid hypotension! Tolerate respiratory depression but try to avoid intubation

9 First line Buccal MDZ vs Rectal DZP 219 episodes involving 177 patients! 2-3 doses of benzodiazepines! Access can be challenging in children! IV vs. IM vs. buccal vs. IN Median age 3 years! Cessation of seizures in 10 mins for at 1 hour! terminated 56% MDZ vs 27% DZP! Same side effects McIntyre J, Lancet 2005 Intranasal MDZ vs Rectal DZP RAMPART 188 seizure episodes! MDZ superior to DZP! time to delivery! IM MDZ vs IV LZP! Upon arrival to ED seizures were absent in 73% IM MDZ vs 63% IV LZP time to seizure cessation Bhattacharyya M, Pediatr Neurol 2006 May Silbergleit R, NEJM 2012 Feb

10 Benzo summary 2nd line No head to head trial of IV vs IN/buccal! Potentially assume than IN/buccal is as good as IV! Try to establish IV access but don t delay initial benzo dose and use alternate route IV fos-phenytoin 30mg PE/kg! Can infuse over 10 minutes! Risk of hypotension but minimal 3rd line Prepare for PICU transfer! <2 years IV phenobarbital 20mg/kg, may repeat! >2 years IV valproate (Depacon) 20mg/kg! limited data on levetiracetam (Keppra) Conclusions Diagnosis of pediatric seizures can often be made by history! Most patients do not need extensive acute evaluation.! In those high risk groups targeted diagnostic evaluation is appropriate! Treatment of acute repetitive seizures and status epileptics should be systematic and anticipatory