Download step by step management of dka - The Department of Pediatrics of

STEP BY STEP
MANAGEMENT OF
Seizures /
STATUS EPILEPTICUS
Dr. D. Alvarez
2007
INITIAL PROCES
1.
Call from the ED requesting bed for a patient with Seizures /
Status Epilepticus.
2. PICU Resident / Supervisor (if applicable) obtains
information on patients condition, on the phone or going to
the ED.
3.
Information needed:
A. Base line patient’s: Previously healthy Or if any chronic
condition.
-
If previous diagnosed with Seizures > since ? age
Taking medications? Name, doses, Since when
-
-
time last dose ?, did tolerated or vomited?
Follow up by Neurology? Last visit
Previous studies (head CT, MRI)
Seizure control
Last Hospitalization?; intubation?; ED visit?
INITIAL PROCES (continue)
B. Is this is first Episode?
Information of Current event/exacerbation:
• Triggering factors, fever? Trauma?, medications?
Or No obvious triggering /“Unprovoked”
• Describe seizures,
–
–
–
–
•
-
Focal?, generalized
Onset: when awake ?, sleeping?, watching TV?
Duration
Interventions?
Treatments / management at home.
EMS, findings - treatments if applicable
ED Events… (continue)
4.- Review ED-Events
–
–
–
–
–
–
Condition on arrival > mental status Post ictal?
Airway maintainable? / intubated for airway protection
(Fill up Mechanical Ventilation Order guidelines if
applicable)
Studies / labs done (Start laboratory flow sheets record)
Radiological studies: Head CT, CxR
Lab reports
Treatments given: note, dose and time.
5.- Communicate with PICU Attending and inform on
patient’s condition using the “30 sec assessment
guideline”
6.- Inform PICU Nurses that patient was accepted and
up-date them on patient’s condition.
ASSESSMENT
Physiological Problems that need
to be Address / Assess.
1. Is Airway maintainable? / Secured (intubated)
2. Is Ventilation and oxygenation adequate
•
•
•
O2 Sats RA or % O2 needed
RR, deepness of respiratory effort, air entry.
ABG if patient is intubataed
3. Mental Status changes, any effect of medications
given.
4. Focal neuro findings?
•
Pupilary reaction
3. Cardiovascular Assess
–
–
HR, Rhythm / Tachycardia
BP: Hypertension, hypotension, perfusion.
4. Hydration Status / Fluid-Electrolyte and ABB.
–
–
–
FS: hyperglycemia / hypoglycemia
Hyponatremia / hypernatremia
Metabolic acidosis
Assessment > If associated infection
Process.
•
By History
–
–
–
–
–
•
•
Fever
Respiratory symptoms
GI symptoms: vomiting / diarrhea
Travelinig
Contacts.
By Physical exam
By Studies:
– CBC with diff (manual count) if clinically
indicated
– CxR, (if respiratory symptoms) looking for signs
of aspiration.
– Blood, U/A, CSF culture if indicated.
MANAGEMENT
Initial Management (0-10min)
1. ABC
•
•
•
•
OXYGEN should be given to all pat.actively seizing
and/or alter mental status.
Open airway
Position patient
Assess if adequate ventilation
•
•
Observe for depth of respiration
Listen for air entry
2. Start IV
•
•
Check FS
Send for basic studies (CBC, Lytes)
Initial Management (10-20min)
2. If hypoglycemia give
•
D25 > 2 ml/kg
3. Anticonvulsant Medication (see precalculated
dose/drip protocole)
– Lorazepan 0.1 mg/kg (2 mg/min)
OR
–
Diazepan 0.2 mg/kg (5mg/min)
OR
–
Diastat PR
•
•
•
1-5 y ……….. 0.5 mg/kg
6-10 y ……….. 0.3 mg/kg
> 12 y ……….. 0.2 mg/kg
Repeat ONCE if seizure does not stop within 5-10 min
Management Cont. (20-40min)
Keep Patient on continues C-R monitoring with
–
–
frequent VS including BP and
monitoring A&B, keep airway open and continue
given oxygen.
4. Fosphenytoin:
–
–
20 mg/kg (slow infusion 150 mg/min, pat. On continuous
monitoring)
If seizure persist, give additional 10 mg/kg
AND / OR
5. Phenobarbital
–
20 mg/kg (50 mg/min)
POST BOLUS BLOOD LEVEL SHOULD BE DONE IN
1-2 HRS POST INFUSION.
Management > 60 min)
Refractory Status
– Intubate
• Premedicate with:
– Midazolan:
» 0.1 –0.3 mg/kg Load F/U by
» 0.05-0.4 mg/kg/hr Maintenance
And / OR
– Pentobarbital
» 5-20 mg/kg load
» 0.5-5 mg/kg/hr Maintenance
Intubation Process
1. Call anesthesia (Emergency Beeper
posted) if PICU attending not in house)
2. Calculate / Order / Prepare Medications
• Rapid Sequence (RSI) INTUBATION
MEDICATIONS
 Midazolam: 0.05 to 0.1 mg/kg
– Pentobarbital
» 5-20 mg/kg load
» 0.5-5 mg/kg/hr Maintenance Call
Respiratory therapy
Principles of Mechanical
Ventilation Support
1. Order initial Mechanical Ventilatory
setting according to guidelines after
discussion with PICU attending
2. Continues drip (if indicated) with:
•
•
Midazolan: 0.05-0.4 mg/kg//min
OR
Pentobarbital: 0.5 – 5mg/kg/hr.
Fluid Therapy
NPO until patient is awake and responsive
Calculate patient’s maintenance fluids
(requirements); Wt. base OR per SA(m2)
A. Basic Requiremente
•
•
Wt base:
• 100 ml/kg for the first 10 kg
• 50 ml/kg for the next 10 kg
• 20 ml/kg for the rest…. kg.
Per SA (m2) 1500 mL/M2
B. Add Insensitive extra loses given by:
•
•
Tachypnea
Fever
Check electrolytes, follow up Glucose
Dilantin (To be use only in case that
phosphenitoin not available)
• Remember, this is consider a High Risk Medication, because serious
side effect if not given correctly.
• This are the recommendations
– Dilute only in Normal Saline just before infusion. Not soluble in D5W and
will precipitate.
– 1 gm in 100 mL OR 500 mg in 50 mL of NS
– Infusion rate at no faster than 50 mg/min by pump.
• 5 mL/hr of either solution 1 gm in 100 ml or the 500 mg in 50 mL of NS
solution
–
–
–
–
Monitor EKG and BP during infusion
Do not give Dilantin IM
The dose is 15 to 20 mg/kg
Adverse reactions: Hypotension, Bradicardia, phlegitis, purple glove
syndrome.