Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
GUIDELINE FOR EMERGENCY DEPARTMENT MANAGEMENT OF THE FIRST SEIZURE IN THE PEDIATRIC PATIENT THE FIRST RECOGNIZED SEIZURE IN A CHILD > 8 WEEKS Final 6/19/12 EXCLUDES PATIENTS PRESENTING WITH ABSENCE SEIZURE; FEBRILE SEIZURES; INFANTS ≤ 8 WEEKS INITIAL TREATMENT Rescue Medications For Active Seizure 1 Patient Enters ED Or Start Of Observed Seizure ESTABLISH IV DRAFT 14* ACCESS 2/7/12 YES > 6 MONTHS 5 MIN No MENTAL STATUS MONITOR PHYSIOLOGIC LABS: CBC, CMP HEAD CT WITHOUT CONTRAST CONSIDER LUMBAR PUNCTURE SEIZURE STOPPED? POSTICTAL OR BASELINE LABS LABS2 CBC, CMP CBC & CMP CONSIDER TOXICOLOGY CONSIDER TOXICOLOGY RED, PURPLE, & GREEN TOP TUBES 0 .1mg/kg IV MAX DOSE 4MG NON-ACTIVE SEIZURE 2 ≤ 6 MONTHS LORAZEPAMΨ 5 MINUTES 10 MIN ACTIVE SEIZURE ASSESSMENT AIRWAY VS & O2 SAT WEIGHT PHYSICAL EXAM REPEAT LORAZEPAM 0.05 - 0.1MG/KG IV MAX DOSE 4MG Ψ EMERGENT HEAD CT NO PREDISPOSING CONDITIONS FOR ADMINISTER RESCUE MEDICATIONS1 CONSIDER DIAGNOSTIC EVALUATION2 IF CLINICALLY INDICATED ED CAREGIVER INITIATED PROTOCOL: SEIZURES-ACTIVE: (POLICY # 5-14) POSITION TO MAINTAIN AIRWAY OXYGEN AND SUCTION SET UP AT BEDSIDE MONITOR: CARDIAC/RESPIRATORY MONITOR, PULSE OX & OBTAIN FULL SET OF VS PLACE PATIENT ON O2 AS NEEDED TO KEEP OX SATS >93% (NON-REBREATHER) ESTABLISH IV ACCESS AND DRAW & HOLD BLOOD YES SEIZURE STOPPED? SEIZURE PRECAUTIONS CONSIDER POC CG8 ACUTE INTRACRANIAL PATHOLOGY 5 MINUTES INDICATED IS NOT ROUTINELY NECESSARY IF PATIENT HAS: PARAMETERS AS RETURNED TO BASELINE NORMAL PHYSICAL EXAM EMERGENT CT WITHOUT CONTRAST IS RECOMMENDED IF: ABNORMAL EXAM (INCLUDING MENTAL STATUS) PREDISPOSING HISTORY No 15 MIN HISTORY ALLERGIES MEDICATION SEIZURE DISORDER EPILEPSY CNS OR MEDICAL DISORDER 2 DIAGNOSTIC EVALUATION FOSPHENYTOIN 20mg PE/kg IV/IO MAX DOSE 1500 MG PE INFUSE OVER 7-10 MINUTES 10 MINUTES NO YES SEIZURE STOPPED? EKG: CONSIDER IF HISTORY SUGGESTIVE OF CARDIAC ETIOLOGY TREAT AS STATUS EPILEPTICUS (SEIZURE LASTING 30 MINUTES) STOP AND PROCEED TO DIAGNOSTIC EVALUATION PENDING ORDERS FOR LABS POST SEIZURE MANAGEMENT DISCHARGE CRITERIA IF SEIZURE ACTIVITY RECURS, PROCEED TO RECOVERED FROM SEIZURE RETURNED TO BASELINE MENTAL STATUS IF DIAGNOSTIC TEST PERFORMED, RESULTS DO NOT REQUIRE ACUTE INTERVENTION CONSIDER PARENT/CAREGIVER ANXIETY AND ABILITY TO ACTIVE SEIZURE MANAGEMENT UNDERSTAND EDUCATION MONITOR UNTIL PATIENT RETURNS TO BASELINE MENTAL STATUS SEIZURE PRECAUTIONS PROVIDE SEIZURE EDUCATION: TREATMENT PLAN SEIZURE VIDEO (NEW 5 MIN VIDEO) RECTAL DIAZEPAM IF BEING PRESCRIBED CONSULT NEUROLOGY: 3 STARTING ANTIEPILEPTIC CONSIDERATION FOR ADMISSION STATUS REQUIRING MULTIPLE MEDICATIONS PAGE 1 OF 2 DISCHARGE HOME ORDERS FOLLOW-UP WITH PCP OFFER # FOR NEUROLOGY REFERRAL OR FIRST SEIZURE CLINIC PROVIDE SEIZURE EDUCATION ( SEIZURE TEACHING SHEET) CONSIDER RECTAL DIAZEPAM PRESCRIPTION & EDUCATION NOTIFY CASE MANAGER FOR FOLLOW-UP PHONE CALL FOLLOW-UP PHONE CALL WITHIN 72 HOURS: IS YOUR CHILD BACK TO HIS/HER NORMAL ACTIVITIES OF DAILY LIFE? DID YOU GET YOUR MEDICATION? WHEN IS YOUR APPOINTMENT? ADMISSION CRITERIA CONSULT NEUROLOGY CONSIDER GENERAL CARE ADMINISTRATION OF FOSPHENYTOIN SEDATED FROM DRUGS NOT AT BASELINE OR PROLONGED POSTICTAL PHASE MULTIPLE SEIZURES DIAGNOSTIC TEST RESULTS INDICATE INTERVENTION/OBSERVATION IS NEEDED CONSIDER PICU GEN CARE CRITERIA PLUS: PATIENT DOES NOT HAVE FULL RECOVERY BETWEEN SEIZURE ACTIVITY FREQUENCY OF SEIZURE AND PERVASIVE SEIZURE ACTIVITY PICU ADMISSION CRITERIA: RESPIRATORY DEPRESSION &/OR CONCERN FOR AIRWAY PERSISTENT STATUS EPILEPTICUS DEVELOPED THROUGH THE EFFORTS OF CHILDREN'S HEALTHCARE OF ATLANTA AND PHYSICIANS ON CHILDREN’S MEDICAL STAFF IN THE INTEREST OF ADVANCING PEDIATRIC HEALTHCARE. THIS PATHWAY IS A GENERAL GUIDELINE AND DOES NOT REPRESENT A PROFESSIONAL CARE STANDARD GOVERNING PROVIDERS' OBLIGATION TO PATIENTS. ULTIMATELY THE PATIENT’S PHYSICIAN MUST DETERMINE THE MOST APPROPRIATE CARE. Final 6/19/12 GUIDELINE FOR EMERGENCY DEPARTMENT MANAGEMENT OF THE FIRST SEIZURE IN THE PEDIATRIC PATIENT ADDITIONAL INFORMATION 1 RESCUE MEDICATION DOSING INSTRUCTIONS: LORAZEPAM: Ψ IF PATIENT HAS HAD BENZODIAZEPINE DURING TRANSPORT, CONSIDER PROCEEDING DIRECTLY TO FOSPHENYTOIN *IF NO IV ACCESS NASAL MIDAZOLAM: 0.2MG/KG, MAX DOSE 10MG USE MUCOSAL ATOMIZER DEVICE: MAX DOSE IS 5MG OR 1ML PER NARE REPEAT DOSE IN 5 MINUTES FOR A MAXIMUM OF 2 DOSES & PROCEED TO FOSPHENYTOIN IV/IO IM MIDAZOLAM: 5 mg for 13-40 kg body weight; 10 mg for>40 kg IF SEIZURE ACTIVITY CONTINUES FOSPHENYTOIN: INFUSE OVER 7 -10 MINUTES. TAKES 10 MIN TO CONVERT BEFORE IT WILL STOP SEIZURE ACTIVITY. PE MEANS PHENYTOIN EQUIVALENTS 2 DIAGNOSTIC TESTING LABS: AFTER 6 MONTHS OF AGE IN PREVIOUSLY HEALTHY CHILDREN WHO HAVE RETURNED TO BASELINE , THE YIELD OF LABORATORY SCREENING WITH NEW ONSET UNPROVOKED SEIZURE IS VERY LOW. LUMBAR PUNCTURE: EVIDENCE DOES NOT SUPPORT ROUTINE LUMBAR PUNCTURE (LP) IN UNPROVOKED SEIZURE UNLESS PATIENT HAS SIGNS AND/OR SYMPTOMS OF MENINGITIS OR ENCEPHALOPATHY IMAGING: EMERGENT CT OF HEAD IS NOT ROUTINELY NECESSARY IF PATIENT HAS NO PREDISPOSING CONDITIONS FOR ACUTE INTRACRANIAL PATHOLOGY, HAS RETURNED TO BASELINE AND HAS A NORMAL PHYSICAL EXAM. CT INDICATIONS: ABNORMAL NEUROLOGIC EXAM AND/OR PREDISPOSING HISTORY: MALIGNANCY CLOSED HEAD INJURY (CHI) NEUROCUTANEOUS DISORDER NONACCIDENTAL TRAUMA (NAT) ABNORMAL FINDINGS VP SHUNT PRESENT DURING OUTPATIENT EVALUATION, MRI IS PREFERRED FOR DETECTION OF STRUCTURAL BRAIN ABNORMALITIES, TO ASSESS THE RISK OF RELAPSE, AND TO GUIDE THERAPEUTIC MANAGEMENT FOR PATIENTS WITH CRYPTOGENIC AND REMOTE SYMPTOMATIC EPILEPSIES. PARTIAL SEIZURE WITH NORMAL RECOVERY AND NORMAL NEUROLOGICAL EXAM DOES NOT REQUIRE IMAGING UNLESS < THAN 6 MONTHS EKG: IF HISTORY IS SUGGESTIVE OF CARDIAC ETIOLOGY: EXERCISE INDUCED SEIZURE FAMILY HISTORY OF SUDDEN CARDIAC DEATH < 50 YEARS OLD 3 STARTING ANTIEPILEPTIC THERAPY THE MAJORITY OF PATIENTS PRESENTING WITH A NEW-ONSET SEIZURE WILL NOT REQUIRE THE INITIATION OF ANTI-SEIZURE MEDICATION PRIOR TO OUTPATIENT EVALUATION. CONSIDER STARTING ANTIEPILEPTIC THERAPY IN THE EMERGENCY DEPARTMENT IF THERE ARE RISK FACTORS FOR RECURRENCE AND AFTER CONSULTATION WITH NEUROLOGIST. RISK FACTORS FOR RECURRENCE: REMOTE SYMPTOMATIC SEIZURES FAMILY HISTORY OF SEIZURES ABNORMAL EXAM ABNORMAL IMAGING STATUS EPILEPTICUS PREDISPOSING CONDITIONS SUCH AS CP, MODERATE TO SEVERE DEVELOPMENTAL DELAY, OR HISTORY OF TRAUMATIC BRAIN INJURY DIATSTAT DOSING: 2-5 year: 0.5 mg/kg 6-11 years; 0.3 mg/kg >12 years: 0.2 mg/kg QUALITY MEASURES ADMISSION RATES GENERAL CARE & ICU LOS IN ED RESOURCE UTILIZATION: MEDICATION LAB TEST CT MRI RETURN TO EMERGENCY DEPARTMENT WITHIN 30 DAYS FOLLOW-UP VISITS WITH NEUROLOGY EDUCATION PROVIDED IN EMERGENCY DEPARTMENT DEVELOPED THROUGH THE EFFORTS OF CHILDREN'S HEALTHCARE OF ATLANTA AND PHYSICIANS ON CHILDREN’S MEDICAL STAFF IN THE INTEREST OF ADVANCING PEDIATRIC HEALTHCARE. THIS PATHWAY IS A GENERAL GUIDELINE AND DOES NOT REPRESENT A PROFESSIONAL CARE STANDARD GOVERNING PROVIDERS' OBLIGATION TO PATIENTS. ULTIMATELY THE PATIENT’S PHYSICIAN MUST Page 2 of 2 DETERMINE THE MOST APPROPRIATE CARE.