Ncpg Seizures

SEIZURES Dr Jonny Taitz, FRACP Geschn Paediatrician Sept 2003

Introduction  Common  8% of children will have a seizure by 15 years of age

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Seizure Sudden Attack of altered behaviour ↓ LOC abnormal sensation, automatic function

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Most Common Tonic (stiffening) Clonic (jerking) Absence Myoclonic Atonic Focal MOST ARE BRIEF TERMINATE SPONTANEOUSLY 50% in childhood = febrile convulsion 4

Which seizures do we treat? > 5 minutes Status epilepticus

brain hypoxia

Generalised seizures > 30 mins OR  Repeated convulsions > 30 mins with NO recovery & consciousness between convulsions 

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Complications  Age related  

> 3 yr - 6% < 1 yr - 30%

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- Long term epilepsy - Motor problems - Learning & behavioural problems

 5% mortality (1/20)

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Guidelines aim     

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JHH clear, succint guidelines in the care of acute seizures SHC CHW Many different anticonvulsants Different routes of administration    

Intravenous Intramuscular Rectal Oral

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Important Seizures < 15 minutes much more likely to respond to Rx than seizures > 15 minutes

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History ? Febrile illness 1° assessment Underlying CNS problems ABC History of epilepsy Head trauma toxin ingestion

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Specific features on exam Airway Breathing Circulation Neurological

intubation hypoventilation, aspiration, O2, mask ventilation shock, fluid boluses

RIP,

Underlying illness head injury,

focal signs, ↓ LOC, ↑ asymmetrical seizures

trauma, meningitis, metabolic

abnormalities 10

Management Priority no 1: ABC Airway (Control seizures control airway) Breathing    

Effective and efficient All fitting kids → high flow O2 NB: repeated seizures high dose anticonvulsants

 Circulation  

Rx shock Fluid Boluses

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Resp depression ? Intubate + ventilate

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Management

(contd)

NEVER FORGET!!! GLUCOSE + BP  Hypoglycaemia 

Rx 5mls/kg 10% Dextrose

 Hypertension  

Antihypertensives: (I.e nifedipine, hydralazine)

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Questions to ask Do I have vascular access? What anticonvulsants are available? How many minutes has the child been fitting? 13

Vascular Access Yes Diazepam 0.25mg/kg IVI Or Midazolam 0.15mg/kg IVI 5 Repeat Diazepam IVI Or Midazolam IVI

No

Supportive measures

Diazepam 0.25mg/kg PR Or Midazolam 0.15mg/kg IMI Access

ABC

No 10 LOAD Phenytoin 20 mg/kg IVI or Phenobarb 20mg/kg IVI

repeat Diazepam or Midazolam

20 Rapid sequence induction Thiopentone, Atropine, Suxemethonium

Paraldehyde 0.4mg/kg PR Dilute 50:50 (olive oil) 14

A little more on anticonvulsants  Diazepam  

 

Effective first line in 80% Rectal admin → therapeutic levels 5 minutes Rapid seizure control (80%) S/E 9% risk of respiratory depression  Higher in children with CNS abnormalities

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A little more on anticonvulsants  Midazolam 

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NSW Ambulance drug of first choice in status epilepticus (IMI) Will stop majority of seizures within 1 minute (IVI) Takes longer when used IM  (approx 5-10 mins)

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Intransal midazolam  More info required before recommending it 16

Midazolam

(contd)

 Paraldehyde Used since 1930’s  Very dangerous IVI  Well tolerated rectally  Rapid onset of seizure control  Less respiratory depression than Benzodiazepines  Smells 

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Questions

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