Evaluation and Management of Pediatric Seizures Nikki Mehta, MD Pediatric Neurology Floating hospital for children at Tufts medical center May 9, 2019 Pediatric emergency medicine, echo lecture

Objectives To define seizures and epilepsy To categorize type of seizure and identify characteristics that warrant additional evaluations To differentiate simple from complex febrile seizure To review treatment strategies for status epilepticus

Disclosures None

What is a seizure? Seizures are defined as abnormal, excessive synchronous neuronal activity in the brain A. normal EEG B. seizure

What is Epilepsy? Epilepsy is diagnosed when a person has had 2 or more unprovoked seizures occuring greater than 24 hours apart OR one unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two seizures (60%) occuring over the next 10 years Untreatable Tumors Scarring from a prior infarction The presence of an epileptogenic brain malformation The diagnosis of an Epilepsy Syndrome

Classification of Seizures Generalized Tonic Clonic Seizure Absence Myoclonic Atonic Focal Simple motor Complex partial Sensory or Autonomic

Partial Seizures

Sensory and Autonomic Seizures Or seizures can occur in various areas of the cortex that are involved in sensory processing Occipital Lobe- Visual Hallucinations/Auras Medial and Lateral Temporal Lobes- Auditory Hallucinations (formed or simple) Insular cortex – Visceral and autonomic features- nausea, emesis, sweating and flushing

Febrile Seizures Common in children- up to 4% of all children <5 years of age can have them Occur in the presence of fever, but without signs of CNS infection or other identifiable cause Inclusion Criteria Must fall within typical age range (6 months to 6 years) Must be developmentally normal for age Must not have had prior afebrile seizures Must have fever >38F in association with the seizure

Simple vs Complex Febrile Seizure Why differentiate? Patients with Simple Febrile seizures have a near population risk of development of epilepsy Patients with Complex Febrile Seizures have 5-10% risk of developing epilepsy

Simple vs Complex Febrile Seizure

Febrile Status Epilepticus Febrile Seizures lasting longer than 30 minutes or recurrent episodes of same duration without neurologic recovery in between Treat as Status Epilepticus Consider (strongly) evaluation for CNS Infection

Status Epilepticus The majority of pediatric seizures are self limited to <5 minutes After 5 minutes, likelihood a seizure will stop on its own precipitously drops Internalization of neuronal GABA receptors, up to 20 fold by 30 minutes Convulsive Status Epilepticus is defined as seizure lasting >5 minutes, or recurring without return to neurologic baseline in between

Treatment of Seizures Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Jan 2016 Based on large meta analysis of many RCTs treating both adults and children Guideline is valid for all people >1 month old (same for adults and kids)

Stabilization Phase (0-5 min) Airway, Breathing, Circulation, Neuro Exam Time the seizure onset O2 support Establish IV access Fingerstick Glucose and Electrolyte panel, Tox if appropriate

First Line Therapy Phase (5 -20 min) If seizure continues, administer first line medication IV Lorazepam (0.1mg/kg, max 4mg) , IV Diazepam, or IM Midazolam Treating adequately at first is more likely to stop seizure that repeated small doses Respiratory depression is most common side effect, expect it and prepare airway support if needed Can repeat x 1 if seizure continues after 5 minutes

Second Line Therapy (20-40 min) No clear winner for what to use next IV Phenytoin/Fosphenytoin (20mg/kg x 1) IV Valproic Acid (40mg/kg x 1) IV Levetiracetam (60mg/kg x 1) Consider transfer to center with Pediatric Neurology

DOI: (10.5698/1535-7597-16.1.48)

Workup: Now, Later, Never? Now- Consider Labs, Neuroimaging, and/or EEG Patients with clinical history of partial/focal seizure Patients with persistent focal neurologic deficits- Seizure is a first presentation for ~50% of all Pediatric Strokes! Patients who are not rousing/have prolonged encephalopathy beyond expected postictal period (concern for tox, NAT, encephalitis) Patients with status epilepticus (particularly the first episode) Later- Can be referred to outpatient Pediatric Neurology for consult and workup (1-4 weeks, depending on severity) Patients with first afebrile seizure (of any kind), if back to baseline in ED Patients with complex febrile seizure (clusters, prolonged), now back to baseline

Workup: Now, Later, Never? Simple Febrile Seizure, meeting all inclusion criteria +/- Complex Febrile Seizure if the reason it is complex is >2 in 24 hours