The Fitting Child

Curriculum link: PMP6 The unconscious child

Diane WilliamsonConsultant Emergency MedicineAddenbrookes Hospital

OutlineSeizures

Status epilepticus and the APLS treatment protocol

Febrile convulsions

HypoglycaemiaCausesTreatment/reversal

DKACerebral Oedema – recognition and emergency treatment

Local and National Guidelines

Status Epilepticus generalised convulsion lasting 30min or longer or repeated tonic-clonic convulsions occurring over a 30 minute

period without recovery of consciousness between convulsions

Treatment Guideline

Time 0ABCHigh flow O2Blood glucoseConfirm that it is an epileptic seizure

Consider pre-hospital treatments already given

5 MinutesMidazolam 0.5mg/kg buccally

Or

Lorazepam 0.1mg/kg IV

15 Minutes

Lorazepam 0.1mg/kg IV

Call for senior help

Prepare phenytion

25 Minutes

Phenytoin 20mg/kg IV over 20 minutesOr (if on regular phenytoin)Phenobarbitone 20mg/kg IV over 5 minutes

Consider paraldehyde 0.8ml/kg after start of phenytoin

Inform ICU/Senior Anaesthetist

25 Minutes

RSI with thiopental 4mg/kg IV

Transfer to PICU

Febrile ConvulsionsConvulsions that occur when a child has a febrile illness

Usually self-limiting and not harmful

Age 6 months to 5 years (usually toddlers)

1 in 25 children

Recur in 1/3 and 1/100 develop epilepsy

Risk factors for recurrence<15 months of agefrequent feversimmediate family member with history of febrile seizures

Note – antipyretic agents do not prevent febrile convulsions and should not be prescribed specifically for this purpose

Look for a focus of infection

ENT – ears, pharynxRespiratoryUrinary tractSkinConsider meningitis and encephalitis

Using antipyretics specifically to treat fever is not recommended and does not prevent further seizures

Hypoglycaemia

Glucose <2.6mmol/L

Most common cause is insulin-dependent diabetes

Consider inborn errors of metabolism

Treatment of Hypoglycaemia

Bloods - special samples are needed for glucose, lactate and metabolic screening

LiHep on icefluoride tubesbiochem

Glucose 10% glucose 2 ml/kg (2.5ml/kg for newborns)Glucose infusion

e.g.Glucose 5% 120mg/kg/hrMonitor glucose

DKA

British Society for Paediatric Endocrinology and Diabetes DKA Guideline

DKA CalculatorFluid management

Cerebral Oedema

Cerebral Oedema

HeadacheNeurologic (e.g. restlessness, irritability, drowsiness, incontinence)Decreasing HRIncreasing BPDecreasing SaO2Neurologic signs e.g. cranial nerve palsiesAbnormal posturingSeizures

Management of Cerebral Oedema

Senior help and PICU referralCheck glucose (R/O hypoglycaemia)Hypertonic saline 2.7% 5ml/kg over 5-10minOrMannitol 20% 2.5-5ml/kg over 20minDecrease fluid replacement to ½ maintenanceCT head when stable

Guidelines

NICE CG 137 The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care (2012)

Appendix F: algorithms for Status epilepticus

British Society for Paediatric Endocrinology and Diabetes DKA Guideline (2011)

Update due 2014

BSPED DKA Calculator (2011)

Seizures in Children

Questions?