The Fitting Child Curriculum link: PMP6 The unconscious child Diane Williamson Consultant Emergency Medicine Addenbrookes Hospital

Outline Seizures Status epilepticus and the APLS treatment protocol Febrile convulsions Hypoglycaemia Causes Treatment/reversal DKA Cerebral 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 0 ABC High flow O2 Blood glucose Confirm that it is an epileptic seizure Consider pre-hospital treatments already given

5 Minutes Midazolam 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 minutes Or (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 Convulsions Convulsions 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 age frequent fevers immediate 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, pharynx Respiratory Urinary tract Skin Consider 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 ice fluoride tubes biochem Glucose 10% glucose 2 ml/kg (2.5ml/kg for newborns) Glucose infusion e.g.Glucose 5% 120mg/kg/hr Monitor glucose

DKA British Society for Paediatric Endocrinology and Diabetes DKA Guideline DKA Calculator Fluid management Cerebral Oedema

Headache Neurologic (e.g. restlessness, irritability, drowsiness, incontinence) Decreasing HR Increasing BP Decreasing SaO2 Neurologic signs e.g. cranial nerve palsies Abnormal posturing Seizures

Management of Cerebral Oedema Senior help and PICU referral Check glucose (R/O hypoglycaemia) Hypertonic saline 2.7% 5ml/kg over 5-10min Or Mannitol 20% 2.5-5ml/kg over 20min Decrease fluid replacement to ½ maintenance CT 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?