Seizure Acute Management: Emergency Department v.2.1 Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

Inclusion Criteria · Patient presenting with epileptic seizure

Exclusion Criteria · Age < 1 month corrected age · Non-epileptic events (pseudoseizures)

! Confirm medication history. If seizing upon arrival skip to appropriate step

! Known epilepsy: check outpatient seizure plan

Definitions Prolonged Seizure/Status Epilepticus: seizure longer than 5 minutes or two or more seizures without a return of consciousness between seizures

General Measures

Drug Treatment

· Position child to avoid injury · Cardiorespiratory support as needed · SaO2; support respiration including provision of high concentration oxygen · Make NPO/hold feeds while seizing · Document seizure start time (consider using Code Blue Sheet) · Check Care Plan/Care Coordination for individualized seizure care plan · Prepare/obtain next medication · Consider IV placement

Minute 0 1st Step

· None

Investigations · Confirm clinically that it is an epileptic seizure · Assess risk for infection (if fever, see also Febrile Seizure Pathway) · Investigate prior medications given

Seizure continues

Minute 5 2nd Step

Drugs (1st Line)

General Measures · Above plus · Cardiorespiratory monitoring, blood pressure q 5 minutes · Correct hypoglycemia · Prepare/obtain next medication

IV access · Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access v · Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril

Investigations · Physical examination and history · If on antiepileptic medication: consider drug level · Consider laboratory tests based on individual clinical circumstances

Seizure continues

Minute 15 3rd step

Drugs (1st Line)

General Measures · Above plus · Capnography · Prepare/obtain next medication

IV access · Lorazepam 0.1 mg/kg max 4mg/ dose administered IV 2mg/min No IV access · Midazolam 0.2mg/kg max 10mg/ dose, ½ dose in each nostril

Investigations · Re-confirm clinically that it is an epileptic seizure

Seizure continues

Minute 25 4th Step

Drugs (2nd Line)

Investigations

General Measures

· Order customized treatment plan if available. If not available, use default below:

· Above plus · Use blood pressure (BP) support if needed · Identify and treat medical complications · Consider PICU and Neurology consult · *Decrease loading dose if patient already established on phenobarbital or fosphenytoin

Age 1-2 months old · Phenobarbital 20mg/kg IV loading dose* Age > 2 months old · Fosphenytoin 20mg PE/kg IV*

· As above · Consider CT · Consider EEG

! Watch for B/P changes in patients with cardiac anomalies or hemodynamic instability

Seizure continues

Post-Ictal

Minute >40 5th Step

Drugs (2nd Line) Age 1-2 months old · May give additional phenobarbital 5mg/kg IV doses every 15-30 minutes until 30mg/kg maximum is met* Age > 2 months old · Phenobarbital 20mg/kg IV if seizure continues 15 minutes after fosphenytoin load* · May give additional phenobarbital 5mg/kg IV doses every 15-20 minutes*

Investigations

General Measures

· As above

· Above plus · Off pathway, transfer to PICU · In consultation with Neurology, optimize maintenance antiepileptic drug treatment · *Decrease loading dose if patient already established on phenobarbital or fosphenytoin

Treatment and General Measures · Ongoing vital signs q 10 minutes until stable · Ongoing cardiorespiratory and SpO2 monitoring until return to baseline · Family support · Discuss with primary neurologist

Admit Criteria · Unstable cardiorespiratory or neurologic status (not returing to baseline, very somnolent) · Underlying infection requiring inpatient stay · Disabling parental anxiety · Lack of safe home or safe transportation to home

For questions concerning this pathway, contact: [email protected] © 2016, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

Last Updated: December 2016 Next Expected Review: May 2017

Seizure stops

Seizure Acute Management: Inpatient v.2.1 Approval & Citation

Summary of Version Changes

Explanation of Evidence Ratings

Inclusion Criteria · Patient presenting with seizure · Patient admitted with history of epileptic seizures and risk of recurrence

Exclusion Criteria

!

· Age 2 months old · Fosphenytoin 20mg PE/kg IV*

· As above · Consider CT · Consider EEG

! Watch for B/P changes in patients with cardiac anomalies or hemodynamic instability

Seizure continues

PostIctal

Minute >40 5th Step

Drugs (2nd Line) Age 1-2 months old · May give additional phenobarbital 5mg/kg IV doses every 15-30 minutes until 30mg/kg maximum is met* Age > 2 months old · Phenobarbital 20mg/kg IV if seizure continues 15 minutes after fosphenytoin load* · May give 2 additional phenobarbital 5mg/kg IV doses every 15-20 minutes (total 30mg/kg maximum)*

General Measures · Above plus · In consultation with Neurology, optimize maintenance antiepileptic drug treatment · Off Pathway, transfer to PICU · *Decrease loading dose if patient already established on phenobarbital or fosphenytoin

Investigations · As above

Treatment and General Measures · Ongoing vital signs q 10 minutes until stable · Ongoing cardiorespiratory & SaO2 monitoring until at baseline For questions concerning this pathway, contact: [email protected] © 2016, Seattle Children’s Hospital, all rights reserved, Medical Disclaimer

· Family support · Discuss with primary neurologist Last Updated: December 2016 Next Expected Review: May 2017

Return to ED Management

Return to Inpatient Management

Definition of Prolonged Seizure A proposed Classification of Status Epilepticus according to length of seizure: 5-30 Minutes: (OR 2 or more seizures without returning to baseline): Prolonged Seizure/Early Status Epilepticus.

30-60 Minutes: Established Status Epilepticus. Greater than 60 Minutes: Refractory Status Epilepticus. [Expert Opinion (E)] (Glauser ,2007; Ma, 2010; NICE, 2012)

Definitions Prolonged Seizure/Status Epilepticus: seizure longer than 5 minute or two or more seizures without a return of consciousness between seizures.

Return to ED Management

Return to Inpatient Management

Actively Seizing For the child that is actively seizing, obtain history of all antiseizure medications given around this seizure episode to: •

Prevent medication overdosing

•

Prevent medication interactions

•

Decide where the patient belongs on the pathway •

e.g., the patient that is still seizing at presentation to the ED after receiving 2 doses of benzodiazepines in the field, should proceed to second-line agents after the appropriate time interval.

Return to ED Management

ED:

Inpatient:

Return to Inpatient Management

When should treatment begin? •

Give immediate emergency care and treatment to children, young people and adults who have prolonged (lasting 5 minutes or more) or repeated (3 or more in an hour) convulsive seizures in the community. Serious risk of immediate and long-term morbidity and mortality if convulsive seizure is not terminated by 30 minutes and therefore treatment is required urgently. [ Low quality] (NICE, 2012)

•

Patients arriving at the hospital with a seizure can be considered as having a prolonged seizure. A pre-hospital trial showed that time from seizure onset to initiation of treatment was inversely correlated with the percentage of patients who responded to firstline therapy. Patients receiving first-line therapy within 30 minutes had >80% response rate compared to 75% within 60 minutes and 63% within 90 minutes. [ High quality] (Ma, 2010)

Drug therapy for prolonged seizure Drug therapy for prolonged seizures consists of : • A first-line agent

PLUS

• A second-line agent

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Drug therapy for prolonged seizure – 1st line •

Benzodiazepines are first-line agents. First dose should be given at 5 minutes after start of seizure. Dose may be repeated after 10 minutes if patient still seizing.

•

Administer intravenous lorazepam as first-line treatment in hospital in children, young people, and adults with ongoing generalized tonicclonic seizures.

•

Administer intranasal OR buccal midazolam if unable to secure immediate IV access. [ Low quality] (NICE, 2012)

Drug therapy for prolonged seizure – 1st line •

Administer a maximum of two doses of the first-line treatment (including pre-hospital treatment). [ Low quality] (NICE, 2012)

•

The first dose of the patient’s second-line treatment should be requisitioned from the pharmacy immediately after giving a second dose of benzodiazepine. This gives the pharmacy adequate time to prepare the medication so that it can be given on-time if the patient continues to seize.

Return to ED Management

Return to Inpatient Management

Drug therapy for prolonged seizure – 2nd line •

Second-line therapy after benzodiazepines is fosphenytoin or phenobarbital.

•

Fosphenytoin is preferred for patients age greater than or equal to 2 months.

•

Cardiorespiratory and blood pressure monitoring must accompany the IV administration of Fosphenytoin. [ Very low quality] (Ma, 2010)

First dose of these agents should be given at 10 minutes after the second benzodiazepine dose. Dose may be repeated after an additional 15 minutes if patient still seizing.

Return to ED Management

Return to Inpatient Management

Drug therapy for prolonged seizure – 2nd line Cautions: •

Fosphenytoin has direct cardiac effects which can lead to arrhythmias.

•

Hypotension, though rare, does occur with fosphenytoin.

•

Phenobarbital can cause hypotension from its vasodilatatory and cardiodepressant effects

•

Phenobarbital can cause profound respiratory depression.

Return to ED Management

! Watch for B/P changes in patients with cardiac anomalies

Return to Inpatient Management

Drug Therapy For Prolonged Seizure At Admission: • Order benzodiazepine from Seizure Acute Management First-line Orderset • Order standard second-line medications from Seizure Acute Management Plan OR patient’s customized second-line meds based on Neurology recommendations

• All inpatients with a significant history of seizures should have “as needed” doses of first-line AND second line seizure rescue agents ordered as part of their admitting orders, so that they are readily available. • Some patients with a history of frequent, prolonged and /or intractable seizures may use other agents other than fosphenytoin or phenobarbital for their second-line treatment. Neurology should be consulted for these patients.

Return to ED Management

Return to Inpatient Management

General measures for acute seizure Immediately: • • • • • •

•

Give high-concentration oxygen Assess cardiac and respiratory function Check blood glucose levels Secure IV access in a large vein Secure airway [Expert Opinion (E)] (NICE, 2012) If patient receives a dose of benzodiazepine, continuously monitor and manage cardio respiratory function. [Expert Opinion (E)] Check blood pressure every 5 minutes during seizure, then every 10 minutes during postictal period until stable. [Expert Opinion (E)]

General Measures • • • • • • • •

Seizure

Continues

General Measures • • • •

Return to ED Management

Position child to avoid injury Cardiorespiratory support as needed SpO2; support respiration including provision of high concentration oxygen Make NPO/hold feeds while seizing Document seizure start time (consider using Code Blue Sheet) Check Care Plan / Care Coordination for individualized seizure care plan Prepare/obtain next medication Consider IV placement

Above plus Cardiorespiratory monitoring, blood pressure q 5 minutes Correct hypoglycemia Prepare/obtain next medication

Return to Inpatient Management

Laboratory evaluation for acute seizure •

•

Anti-epileptic drug (AED) levels should be considered when a child with epilepsy on AED prophylaxis develops prolonged seizure/SE.

Investigations •

Confirm clinically that it is an epileptic seizure

[ Low quality] (Riviello, 2006)

•

Assess risk for infection (if fever, see also Febrile Seizure Pathway)

Laboratory tests (complete blood count (CBC), serum electrolytes, blood urea nitrogen (BUN), creatinine, glucose, calcium, magnesium, or stool studies) should be considered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness.

•

Investigate prior medications given

[ Very low quality] (Riviello, 2006)

Investigations •

Physical examination and history

•

If on antiepileptic medication: consider drug level

•

Consider laboratory tests based on individual clinical circumstances

Laboratory evaluation for acute seizure Toxicology testing may be considered in children with prolonged seizure/SE, when no apparent etiology is immediately identified, as the frequency of ingestion as a diagnosis was at least 3.6%. To detect a specific ingestion, suspected because of the clinical history, it should be noted that a specific serum toxicology level is required, rather than simply urine toxicology screening. [ Very low quality] (Riviello, 2006)

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Bacterial cultures for acute seizure •

There is insufficient data to support or refute whether blood cultures should be done on a routine basis in children in whom there is no clinical suspicion of infection. [ Very low quality] (Riviello, 2006)

•

There is insufficient data to support or refute whether lumbar puncture should be done on a routine basis in children in whom there is no clinical suspicion of a CNS infection. [ Very low quality] (Riviello, 2006)

•

A lumbar puncture should be performed in any child who presents with a seizure and a fever and has meningeal signs and symptoms (e.g., neck stiffness, Kernig and/or Brudzinski signs). [ Moderate quality] (AAP, 2011)

Return to ED Management

Return to Inpatient Management

Assess Risk of Meningitis or Intracranial Infection •

A lumbar puncture should be performed in any child with seizure and a fever who is felt to be at SIGNIFICANT RISK for meningitis/intracranial infection. Specific aspects of the history or exam that might suggest meningitis or intracranial infection are outlined in the table below:

[ Low quality] (Baumer, 2004; Selz, 2009; Kimia, 2010; Batra, 2011; AAP, 2011; Fetveit, 2008), [Expert Opinion (E)] (AAP, 2011; BC Guideline, 2011)

More detail on this subject can be found in the Febrile Seizure Learning Module.

Assess Risk of Meningitis or Intracranial Infection Children with the following HISTORICAL features have an increased risk of meningitis and lumbar puncture should be CONSIDERED: •

•

•

A child with at least three days of illness, seen by GP in previous 24 hours, with drowsiness at home, or vomiting at home. [ Low quality] (Baumer, 2004) An infant between 6 and 12 months of age who is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (i.e., has not received scheduled immunizations as recommended) or when immunization status cannot be determined because of an increased risk of bacterial meningitis. [Expert Opinion (E)] (AAP, 2011) A child who is pretreated with antibiotics, because antibiotic treatment can mask the signs and symptoms of meningitis. [Expert Opinion (E)] (AAP, 2011)

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History • >3 days duration of illness • Seen by primary MD in previous 24 hours • Drowsiness or vomiting at home • Infant 6-12 months old deficient in Hib or pneumococcal vaccines or immunization status cannot be determined • Pretreated with antibiotics

Assess Risk of Meningitis or Intracranial Infection Children with the following PHYSICAL EXAM features have an increased risk of meningitis and lumbar puncture should be CONSIDERED: •

Children with petechiae, questionable nuchal rigidity, drowsiness, convulsing on examination, weakness on examination, bulging fontanel. [ Low quality] Baumer, 2004)

•

Some studies have suggested that abnormal neurological or mental status examinations are most predictive of meningitis/ intracranial infection: patients are described as obtunded, comatose, unresponsive, lethargic, drowsy, prolonged postictal state, agitated, combative, irritable, cranky, clingy, moaning, toxic. [ Low quality](Selz, 2009; Kimia, 2010; Batra, 2011; AAP 2011)

•

Signs of infection of the head or neck with potential for intracranial extension (such as mastoiditis, sinusitis, etc.) [Expert Opinion (E)]

•

Physical Signs • Petechiae • Questionable nuchal rigidity • Drowsiness • Convulsing on examination

• Weakness or neurological deficit on examination • Signs of infection of head or neck with potential for intracranial extension (such as mastoiditis, sinusitis, etc.) • Bulging fontanelle

No evidence was found to support the suggestion that children below a certain age do not exhibit the signs of meningitis. (Baumer, 2004)

Assess Risk of Meningitis or Intracranial Infection Children with COMPLEX FEBRILE SEIZURES may have an increased risk of meningitis and lumbar puncture should be CONSIDERED There is some inconsistency in the literature regarding the approach to patients with complex febrile seizures (CFS). •

•

Two guidelines state that LP should be CONSIDERED in children with CFS. [ Low quality] (Baumer, 2004; Fetveit, 2008)

One guideline RECOMMENDS lumbar puncture for all patients with CFS. [Expert Opinion (E)] (Boyle, 2011) And one guideline makes no distinction between children with CFS and children with simple febrile seizures (SFS) when assessing their risk of meningitis/intracranial infection. [Expert Opinion (E)] (BC Guideline, 2011)

Complex Features • Focal Seizures • Seizure duration > 15 minutes • Multiple seizures in 24 hours

•

The PAERG systematic review looked a 4 studies from 1981 -92, and found that the historic pooled rate for meningitis following febrile seizure was 2.9% overall, with a rate of 2% in SFS and 9.1% in CFS. [ Low quality] (PAERG, 2002)

•

However, recent studies in the age of Hib and Pneumococcal vaccines have shown the rate of meningitis CFS to be very low at B

A=B

A