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

2. Case:
Baby R
14 month old
Female
Bulacan

3. Chief Complaint
Generalized seizures

4. 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

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

6. 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,

7. 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

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

9. 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

10. Approach to Diagnosis and Differentials

11. 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

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

13. Approach to Diagnosis
Group of diseases
Generalized Seizures

14. Differential Diagnosis
Status Epilepticus
Febrile Seizures

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

16. 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

17. 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

18. 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

19. 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

20. Discussion and Treatment o

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

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

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

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

25. 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

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

27. 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

28. 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

29. 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

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