The Convulsing Child Flashcards
Define generalised CSE (convulsive status epilepticus).
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
When do you start treatment in generalised CSE and why at this time?
After a seizure has lasted 5 mins or more -
because they may not stop spontaneously.
Name common causes of convulsions in children.
CAUSES OF CONVULSIONS
- Epilepsy (1-5% will have CSE)
- Febrile convulsions / fever (<6 yo) – 5% present w/ CSE
- Meningitis/ encephalitis
- Hypoxia
- Metabolic abnormalities
What are some of the complications of prolonged convulsions?
- General
- hyperthermia
- Resp
- airway obstruction
- hypoxia
- aspiration of vomit
- CVS
- cardiac arrhythmias
- hypertension
- pulm. oedema
- DIC
- Renal
- myoglobinuria
What is the mortality rate status epilepticus in children?
4-6%
Lower than adults
Name some of the adverse neurological outcomes of generalised CSE.
What is their incidence?
ADVERSE NEUROLOGICAL OUTCOMES:
- Epilepsy (persistent)
- Motor deficits
- Learning/ Behavioural difficulties
INCIDENCE:
< 1 year = 29% (~1/3)
> 3 years = 6%
Describe the pathophysiology of prolonged convulsions.
- generalised convulsion
- cerebral metabolic rate increases x 3
- Loss of cerebral arterial regulation AND
- Increased sympathetic activity
- release of catecholamines
- peripheral vasoconstriction
- increased Systemic BP
- Increase in CBF (to provide oxygen and energy)
- Convulsions continue
- Systemic BP falls
- CBF reduces
- lactic acid accumulation
- Cell death
- Cerebral oedema
- Raised ICP
- Worsening cerebral perfusion
Describe the primary assessment and resuscitation of the child with convulsions.
- 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**
- HR + BP
- 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
- Fever - treat with paracetamol/ PR diclofenac
- Purpuric Rash
- meningococcal/ streptococcal sepsis
- Bruising
- NAI
- Insert NGT /OGT & aspirate gastric contents
- Temperature
- 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
What questions should be asked in the history for a convulsing child?
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?
Describe the emergency management of convulsions.
ABCDEFG!!
FOLLOW INDIVIDUAL PROTOCOL IF AVAILABLE.
FOR INFANTS + CHILDREN (NOT NEONATES).
-
LORAZEPAM or MIDAZOLAM/ DIAZEPAM
- 5 mins after convulsion started
-
LORAZEPAM
- 10 mins after STEP 1 STARTED
- +/- PARALDEHYDE
-
PHENYTOIN or PHENOBARBITONE
- 10 mins after STEP 2 STARTED
-
RSI - THIOPENTONE
- 20 mins after infusion started IN STEP 4
-
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
-
Lorazepam – if access established quickly
-
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
- +/- 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
-
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
- Phenytoin
-
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
Which has a longer duration of action
- Midazolam?
- Lorazepam?
Lorazepam: 12-24 hrs + less resp depression.
Midazolam: < 1 hr
Can midazolam/ diazepam be used IV?
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
What are the benefits/ drawbacks of midazolam for terminating CSE?
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
What are the benefits and drawbacks of paraldehyde?
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
Does phenytoin have a depressant effect on respiration?
A little.
