Emergency Case Conference Miranda, M.C. Molina, R.M. Monzon, J.W. Morales , A.R.

Case: Baby R 14 month old Female Bulacan

Chief Complaint Generalized seizures

History of Present Illness 6 episodes of vomiting accompanied by high grade fever Generalized tonic-clonic seizures with upward rolling of eyeballs and circumoral cyanosis Few hours PTC 30 minutes PTC Brought to USTH ER

History of Present Illness She has had recurrent grand mal seizures since birth lasting up to 1 hour Maintained on Carbamazepine and Topiramate

Physical Examination VS: PR 180 bpm, RR: 28 cpm, Temp: 40.3, O2 saturation : 82% Skin: Pale, warm to touch, diaphoretic HEENT: no gross lesions, pale palpebral conjunctiva, anicteric sclera, pupils 2-3 mm ERTL, nasal septum midline, turbinates not congested, no nasal discharge, moist buccal mucosa, no oral ulcers, tonsils not enlarged, non hyperemic EAC, intact tympanic membrane, supple neck, no palpable cervical lymphnodes,

Physical Examination Chest: adynamic precordium, Apex beat 4th L ICS MCL, no murmurs Lungs: Symmetrical chest expansion, no retractions, resonant, clear breath sounds Abdomen: Normoactive bowel sounds, soft, non tender, no masses Extremities: No deformities, pulses full and equal

Initial management was done however, the patient continued to seize despite the initial management.

Other pertinent information Ask about the character of the seizure Ask about the relationship of the fever and the seizure Ask about the dose of the medications and compliance of taking the medications Ask about any other signs or symptoms of infection, changes in sensorium or other previous illnesses Ask about the birth history of the patient Ask about any family history of seizures

Approach to Diagnosis and Differentials

Salient Features from History 14 month old baby girl Generalized seizures Recurrent grand mal seizures since birth Maintained on Carbamazepine and Topiramate 6 episodes of vomiting

Salient Features on Physical Examination High grade fever Generalized Tonic-Clonic seizures Upward rolling of eyeballs Circumoral cyanosis Tachycardic

Approach to Diagnosis Group of diseases Generalized Seizures

Differential Diagnosis Status Epilepticus Febrile Seizures

Status Epilepticus (Definition) A continuous convulsion lasting longer than 30 mins Occurrence of serial convulsions with no return of consciousness in between Generalized Partial

Etiology Most common cause : Idiopathic A febrile seizure lasting for more than 30min in a child younger than 3 yr of age Idiopathic Sudden withdrawal of anticonvulsants Irregular intake Non-compliance

Febrile Seizures (Definition) The most common seizure disorder in childhood Age dependent Rare before 9 mo and after 15 yr of age Peak age of onset: 14 – 18 mo of age

Clinical Manifestations Core temperature that increases rapidly to ≥39°C Seizure is usually generalized, tonic-clonic Lasts for a few seconds to 10min Followed by a brief postictal period of drowsiness

Px’s Salient Features Status Epilepticus Febrile Seizures Age 14 months < 3 years 14 – 18 months Type of convulsion GTC Generalized or Partial Usually GTC Duration 30 min – 1 hr > 30 min Few sec to 10 min Recurrence + Serial seizures with no return of consciousness in between Usually followed by a brief postictal period of drowsiness Upward rolling of eyeballs +/- Vomiting Circumoral cyanosis Pallor Tachycardia Diaphoresis

Discussion and Treatment o

Status Epilepticus Continuous seizures lasting longer than 30 minutes or successive seizures between which there is no return of consciousness

Types Tonic-clonic (grand mal) Simple partial (focal) Complex partial Absence Myoclonic Most life threatening is tonic clonic

Etiology Hypoxia Brain tumors Hypoglycemia Meningitis Sudden withdrawal or underdosage of anticonvulsants Brain tumors Meningitis Encephalitis Trauma

Clinical Manifestations Profound tonic/clonic activity Loss of consciousness Ictal discharges on EEG

Goals of Treatment Ensure adequate brain oxygenation and cardiorespiratory function Terminate clinical and electrical activity as soon as possible Prevent recurrence Identify precipitating factors Correct metabolic imbalance Prevent systemic complications

Treatment First line Drugs: Diazepam, Lorazepam Second line Drugs: Phenytoin, Phenobarbital, and Valproic Acid

Treatment 0-5 mins Get a good history and diagnose clinically Maintain good ABC’s Monitor vital signs, ECG, EEG, glucose level, blood chemistry, toxic screening, and ABG Insert IV line: plain NSS

Treatment 5 mins onwards 10 mins Give 2-4 mg/kg of 25% glucose solution by bolus injection Give IV lorazepam 0.1mg/kg by IV push IV diazepam at 0.3 mg/kg by IV push or rectally 10 mins Give second dose if seizures are not controlled

Treatment If seizures are persistent a.) Phenytoin 20 mg/kg (maximum of 10 mg in 1ml, 1 mg/kg/min) b.) Phenobarbital loading dose of 20 mg/kg IV bolus (elective intubation) c.) IV phenobarbital over 10 mins if under maintenance oral phenyotin

Treatment If seizures are still present Intensive care facilities are recommended Diazepam or Midazolam infusion Barbiturate Coma General anesthesia (Thiopental or Propofol)