Download ≤ 6 MONTHS > 6 MONTHS Rescue Medications For Active Seizure

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.