Download Seizure Presentation from 2-11-14 CPPQC Meeting PPT

Pediatric Prehospital Seizure
Management:
Evidence Based Guidelines and
State of Care in CO
Kathleen Adelgais, MD MPH
Pediatric Emergency Medicine
Children’s Hospital Colorado
Introduction
• Seizures are most common neurologic
disorder in children
• About 5% of all children will have at least 1
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seizure within first 16 years
Up to 10% of ambulance calls for children are for
seizure activity
Approximately 1.5% of total ED visits by children
are for seizure-related complaints
Pathophysiology
• Excess neuronal discharge activity within the
brain:
 Increased glucose & O2 consumption
 Increased CO2 & lactic acid production
• Initial autoregulatory mechanisms compensate
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with increased cerebral blood flow
Brief seizures rarely produce any lasting effects
Pathophysiology
• Prolonged seizure activity can result:
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Lactic acidosis
Rhabdomyolysis
Hyperkalemia
Hyperthermia
Hypoglycemia
Shock
Pulmonary failure
Permanent neuronal injury
• Permanent neuronal injury probably does not occur
until status lasts for longer than 1 hr
Seizures in CO Prehospital Care
Make up approximately 10% of top 75% of
prehospital calls
Total number of children: approximately 2300/yr
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N=405
Proportion of benzodiazepines given
405 patients treated with benzodiazepines in
prehospital setting
Majority treated with Midazolam: 64%
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Goals of Seizure Management
• Rapid stabilization of cardio-respiratory function
• Termination of clinical and electrical seizure
activity
• Treatment of life-threatening precipitants
• Recognition & minimization of adverse physiologic
consequences
Goals of Seizure Management
• Prehospital:
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Oxygen
Glucose check and treatment
Benzodiazepines
Transport
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PREHOSPITAL TREATMENT:
EVIDENCE-BASED GUIDELINE
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Lorazepam
• Historically used in ED setting
• Known respiratory depression and hypotension
 Less respiratory depression & fewer ICU admissions
in comparison to diazepam
• Duration of action: 12-24 hrs
• Dose: 0.1mg/kg IV/IO (max 4 mg)
Diazepam
• Historically used in prehospital setting
 Now seen in home treatment of seizures
• Respiratory depression, somnolence, hypotension,
ataxia, bradycardia
• Duration of action: up to 4 hrs (redistributes from
CNS quickly)
• Can be used both IV and rectally
• IV/IO dose is 0.05 mg/kg to max of 5 mg
• PR dose is 0.3 mg/kg to max of 10 mg
Midazolam
• Benzodiazepine with good efficacy to stop
seizures
• Duration of action: 2-6 hrs
• Can be given intravenously, intranasal, and
intramuscularly
 IV/IO/IM dose is 0.1 mg/kg to max of 5 mg
 IN dose is 0.2 mg/kg to max of 10 mg
• Note: For IN administration use the MAD
Nasal™ for better drug delivery
Mucosal Atomization Device (MAD
Nasal™)
• Great for use in prehospital
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setting
Allows for non-parenteral drug
delivery
Great in pediatrics where IV
access can be challenging
Medications
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Fentanyl
Naloxone
Midazolam
Cardiac medications
Glucagon
Source: http://www.lmana.com
Prehospital:
IN Midazolam vs PR Diazepam
• Study performed to compare IN Midazolam
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to PR Diazepam for prehospital treatment
of pediatric seizures
Groups were similar in: age, gender,
seizure type
PR Diazepam more likely to:
 Have continued seizure activity upon arrival to
ED
 Require BVM en route
 Require ICU admission after reaching hospital
Prehospital:
Midazolam IM vs. Diazepam PR
• Study comparing Diazepam PR to Midazolam IM
• Retrospectively reviewed 93 patient charts
• Groups similar with regard to age, gender, seizure
type
• No difference in:
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Rates of termination of seizure activity
Recurrence of seizure activity
Need for additional treatment
Need for hospitalization
• One difference: Trend toward need for intubation
in IM midazolam group
Evidence Based Guideline
for Prehospital Pediatric
Seizure Management:
Key Features
• Rapid check of glucose
•
Management of hypoglycemia
with Dextrose, Glucagon
• In setting glucose >60, goal is
immediate cessation of
seizure with NON-parenteral
meds
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IN, Buccal, IM midazolam as 1st
line treatment
• If long transport time,
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consider IV/IO access
Reassessment for seizure
activity after 5 minutes
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IV lorazepam
IV midazolam
IV diazepam
If no IV: dosing of midazolam as
mentioned above
Case Examples
• 6 year old with known seizures estimated weight
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of 20 kg given 2 mg IV midazolam
3 year old with seizure, estimated weight of 19
(Broselow) given 4 mg of IV midazolam
16 mo old with seizure, estimated weight of 10
kg, given 1 mg of IM midazolam, followed by
additional 1 mg when seizure recurred
2 year old with seizure, estimated weight of 15
kg, given 1.5 mg IV midazolam
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Additional Examples
• 8 yo with brain tumor, estimated weight of 42 lbs,
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given 2 mg IV midazolam
9 year old with seizures, no estimated weight,
given 4 mg IV midazolam
3 year old with seizures x 10 min, estimated
weight 20 kg (blue on Broselow), given 3.6 mg IM
midazolam
3 year old with seizures, given 1 mg IN followed
by 1 mg IM. No estimated weight documented
Quality Benchmarks for
Prehospital Seizure Management
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