S2E9: Seizures and Epilepsy - PEM

Welcome back to another PEM episode on TheCase.Report!

Orla is joined by Karl and Stephen, who take us through an important presentation. Thankfully our Adult in the Room Dr Paddy Fitzpatrick is close at hand to keep an eye on their work.

Then the Echo Chamber is back, with Dr Emma Fauteux joining Callum to speak on uses (and limitations) of POCUS in PEM.

Right. Let’s get to it!

Seizures and Epilepsy

• According to the International League Against Epilepsy (ILAE), an epileptic seizure is “a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain”

• The ILAE goes on to define epilepsy as “a disease characterised by an enduring predisposition to generate epileptic seizures and by the neurobiological, cognitive, psychological, and social consequences of this condition”

• Seizures affect 4-10% of children during their lifetime.  (Hauser, 1994). ~10% of new onset seizures present to the ED in status epilepticus. (Singh, 2010)

• Getting a clear description of what happened is essential.

• Red Flags

  • Head injury

  • Developmental delay/regression

  • Preceding headache

  • Bleeding disorder/Anticoagulation

  • Intoxication

  • Focal neurological signs

• Seizure mimics can be very good at that, mimicking this condition and may include

  • Syncope

  • Cardiac dysrhythmia

  • Long QT

  • Breath holding spells with up to 15% having generalised hypoxic seizures

  • Sleep disorders e.g. narcolepsy, cataplexy

  • Migraine

• Status epilepticus

  • Continuous seizure activity for greater than 5 minutes or the occurrence of sequential seizures over a similar period without recovery of consciousness between seizures

• Neonatal status epilepticus

  • Presentation

    • abnormal state of consciousness (eg, hyperalert, irritable, lethargic, or obtunded), diminished spontaneous movements

    •  respiratory or feeding difficulties,

    •  poor tone, abnormal posturing, absent primitive reflexes, or seizure activity

    • At birth with

      • Low APAGARs

      • Low umbilical artery ph or low base excess. 

    • Risk factors 

      • Birth history 

      • Obstetric events

      • Maternal medical history

• Management

  • Typically involves using a first line agent as a maintenance agent later so phenobarbitone is commonly employed as the agent of choice here. Doses started with 20mg/kg slow iv loading dose followed by a repeat 30 mins later where required. 

  • Phenytoin remains the second line agent here, dosing again here is 20mg/kg as a slow IV. 

  • 3rd line agent and the consultants are to be called here, with Keppra as the 3rd line agent (40mg/kg)

First seizure presentation

• Discharge criteria

  • No red flags

  • Child returned to and maintains baseline

  • Isolated self-limiting simple generalised tonic clonic

  • Serious infection excluded

  • Parents educated and satisfied with discharge (including information leaflet)

• Outpatient management including neuroimaging

  • Medical follow up should always be arranged for first seizure

Keppra vs. Phenytoin in S.E Management

• ECLIPSE and Concept Trials on levetiracetam and its role in S.E 

  • A quote from that trial: “Thus, failure to find a difference does not mean that levetiracetam is statistically equivalent to phenytoin.” (Dalziel 2019) 

References

• Dalziel SR, Borland ML, Furyk J, Bonisch M, Neutze J, Donath S, Francis KL, Sharpe C, Harvey AS, Davidson A, Craig S, Phillips N, George S, Rao A, Cheng N, Zhang M, Kochar A, Brabyn C, Oakley E, Babl FE; PREDICT research network. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet. 2019 May 25;393(10186):2135-2145. doi: 10.1016/S0140-6736(19)30722-6. Epub 2019 Apr 17. PMID: 31005386. (https://pubmed.ncbi.nlm.nih.gov/31005386/)

• https://emed.ie/Paediatrics/Neurological/Paediatric_Epilepsy_Status.php

• Farmania R, Garg D, Sharma S. Status Epilepticus in Neonates and Infants. Ann Indian Acad Neurol. 2020;23(6):747-754. doi:10.4103/aian.AIAN_189_20

• Glass HC, Shellhaas RA, Wusthoff CJ, Chang T, Abend NS, Chu CJ, Cilio MR, Glidden DV, Bonifacio SL, Massey S, Tsuchida TN, Silverstein FS, Soul JS; Neonatal Seizure Registry Study Group. Contemporary

• Profile of Seizures in Neonates: A Prospective Cohort Study. J Pediatr. 2016 Jul;174:98-103.e1. doi: 10.1016/j.jpeds.2016.03.035. Epub 2016 Apr 19. PMID: 27106855; PMCID: PMC4925241.

• https://www.rch.org.au/clinicalguide/guideline_index/Febrile_seizure/

• https://www.rch.org.au/clinicalguide/guideline_index/Afebrile_Seizures/

POCUS in PEM

eFAST:

·         Beware of Pitfalls (1)

·         A recent RCT showed that performing FAST didn’t change outcomes (2).

·         There are 2 clinical decision rules that can better help you decide with patients to CT:

o   PECARN rule: https://www.mdcalc.com/pecarn-pediatric-intra-abdominal-injury-iai-algorithm

o   Streck rule (3).

Suprapubic Aspiration:

·         Benefit of US guidance known for nearly 30 years (4)!

Pneumonia:

·         This is the Cochrane review challenging the use of antibiotics for non-severe pneumonia (5).

·         See Lancet 2021 RCT attached for trial done in UK setting. No difference between antibiotics and placebo for LRTIs treated in outpatient setting (6).

·         Therefore, given that the management of pneumonia itself is being challenged, I don’t see how POCUS fits in the management of patients I am sending home. I find it useful for the assessment of pleural effusions in complicated pneumonias.

Echo:

·         This is the article referring to IVC collapsibility and fluid responsiveness (7).

·         PEM clinicians can easily be trained to look at pleural effusion and gross function (8).

US guided IV access:

·         There is greater success and longer longevity of IV line when inserted with US guidance (9).

1.        Baer Ellington A, Kuhn W, Lyon M. A Potential Pitfall of Using Focused Assessment With Sonography for Trauma in Pediatric Trauma. J Ultrasound Med. 2019;38(6):1637-42.

2.        Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, et al. Effect of Abdominal Ultrasound on Clinical Care, Outcomes, and Resource Use Among Children With Blunt Torso Trauma: A Randomized Clinical Trial. Jama. 2017;317(22):2290-6.

3.        Streck CJ, Vogel AM, Zhang J, Huang EY, Santore MT, Tsao K, et al. Identifying Children at Very Low Risk for Blunt Intra-Abdominal Injury in Whom CT of the Abdomen Can Be Avoided Safely. J Am Coll Surg. 2017;224(4):449-58.e3.

4.        Kiernan SC, Pinckert TL, Keszler M. Ultrasound guidance of suprapubic bladder aspiration in neonates. J Pediatr. 1993;123(5):789-91.

5.        Lassi ZS, Padhani ZA, Das JK, Salam RA, Bhutta ZA. Antibiotic therapy versus no antibiotic therapy for children aged 2 to 59 months with WHO-defined non-severe pneumonia and wheeze. Cochrane Database Syst Rev. 2021;1(1):Cd009576.

6.        Little P, Francis NA, Stuart B, O'Reilly G, Thompson N, Becque T, et al. Antibiotics for lower respiratory tract infection in children presenting in primary care in England (ARTIC PC): a double-blind, randomised, placebo-controlled trial. Lancet. 2021;398(10309):1417-26.

7.        Long E, Duke T, Oakley E, O'Brien A, Sheridan B, Babl FE. Does respiratory variation of inferior vena cava diameter predict fluid responsiveness in spontaneously ventilating children with sepsis. Emerg Med Australas. 2018;30(4):556-63.

8.        Miller AF, Arichai P, Gravel CA, Vieira RL, Neal JT, Neuman MI, et al. Use of Cardiac Point-of-Care Ultrasound in the Pediatric Emergency Department. Pediatr Emerg Care. 2022;38(1):e300-e5.

9.        Vinograd AM, Chen AE, Woodford AL, Fesnak S, Gaines S, Elci OU, et al. Ultrasonographic Guidance to Improve First-Attempt Success in Children With Predicted Difficult Intravenous Access in the Emergency Department: A Randomized Controlled Trial. Ann Emerg Med. 2019;74(1):19-27.