E3: Pediatric seizures

Have you ever felt anxious dealing with pediatric seizures? Get expert guidance on our latest EMERGE episode with Dr. Sylvia Owusu-Ansah! Tune in for essential tips on pre-hospital and in-hospital seiures management. Don't miss out on boosting your emergency care skills!

Transcript

mohamed_1_11-18-2024_131805: 0:00

All right, so welcome back again to Emergent EM, your go to podcast for emergency medicine, education, resuscitation, and global empowerment, emergency medicine. I'm really excited about today's podcast episode, delving into a nerve wracking topic basically pediatric seizures. A topic that I always kind of get nervous about, and I'm sure some of you would appreciate some of the insights that will be provided by one of the amazing faculty that always like talking to you, Dr. Sylvia Owusu-Ansah. Dr. Sylvia, just tell us a little bit about yourself and the remarkable work you're doing in the city and beyond the city and globally.

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 0:42

Yes. So thank you, Dr. Hagahmed. I'm so, um, enthused and excited to be on Emerge and honored really. So my name is Dr. Sylvia Owusu-Ansah. I am a pediatrician, pediatric emergency medicine physician. I'm an EMS physician here in Pittsburgh, and the long and short of that is that I take care of sick kids inside and outside of the hospital and en route to the hospital and so I specialize in EMS pre hospital care and making sure there are EMS agencies are ready to take care of our children, both on a local, regional, and federal level. And so I'm really happy and excited to be talking about pediatric seizures today.

mohamed_1_11-18-2024_131805: 1:23

Yeah, like this is like one of the things I always either hear about or see at bedside and I feel like there's always this sense of uneasiness about taking care of a child who just had a seizure. You always feel uncomfortable. You don't feel ready to take to provide the appropriate treatment. I feel like, you know, there's always these kind of like nuances in seizures. So that's why I'm glad you're here. I'm glad you're sharing with us your experiences. Uh, when it comes to terminology or seizure terminologies, I feel like there's so many confusing types. Can you tell us more about that? Like the differences in types of seizures?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 2:01

Yes, of course. So a seizure is, you know, just a surge in electrical activity in the brain that leads to physical manifestations. And sometimes we know what causes that. And sometimes we don't, um, you know, what people usually know is what's known as generalized seizures, um, in which. You have all of the brain is affected and you have movements of the top part of the body or the bottom part of the body or all of it all together, not synchronized in any way, shape or fashion. So there's generalized seizures. Those are the ones we usually see on the TV medical dramas. Um, but particularly in children, there are other types of seizures such as focal seizures. So focal seizures tend to affect like one side of the brain. And so interestingly enough, you see kind of. One side of the body maybe has physical manifestation or just one small area. You might just see like the eye twitching or the arm moving and kind of like a steady motion. And so that's what we call focal seizures. And I think later on this podcast, we'll get more into, you know, how we manage that. And how we look at that. And then there are ones that we just don't know. And they're unknown onset of seizures. We just don't know what causes them. Um, and kind of where they come from. We know that it's from the surge of electrical activity. Um, and, and some examples are, you know, in children, we have things and adults to, um, absence seizures where kids may seem to be staring off into space. And. thought to be daydreaming, but they're actually seizing. They're actually having a surge in electrical activity, but don't seem to be aware of their surroundings. And then when we do a further breakdown, we have what's called provoked seizures, seizures that are provoked, meaning there's something that led to that cause and surge in electrical activity in the brain, such as throbbing. Fevers or infections or trauma, head trauma, uh, in particular, but it could be other types of traumas and then they're unprovoked. And those are a good portion of what we see where we just don't know, um, what the causes of the seizures. And once you've had more than one seizure, we begin to talk about, you might've heard of the term epilepsy. We get to talk about epilepsy as having a history of having various, usually unprovoked seizures. Um, and so, so, yes, there is a myriad. types of seizures out there. But the, you know, the basic concept is consistent. Meaning you have the surge of electrical activity that's causing these physical manifestations that are, that can be very harmful in the long run. If you don't stop those seizures,

mohamed_1_11-18-2024_131805: 4:34

I feel like Sylvia that there tends to be this general misconception that if you had a seizure, you have to be unconscious or somewhat confused. Is that true?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 4:44

not necessarily. It depends. Once again, it depends on this type of seizure and seizures don't have to be prolonged. Uh, for instance, we'll get into it in a little bit, but febrile seizures, for instance, that happen. For kids, it's probably 2 to 5 percent of the population, um, that get febrile seizures, usually anywhere from 6 months to about 5 to 6 years. And in those kids, um, you know, they might have a brief episode of a generalized type of seizure, um, but they, they are conscious. Uh, right away. Um, and so again, it depends, you know, overall, when we talk about the epidemiology of seizures in Children, it's about 1 percent up to the age of 14

mohamed_1_11-18-2024_131805: 5:24

Okay. So that's actually a pretty good number. I mean, uh, it feels like at least in our specialties. Uh, for both of us, you and I, and for a lot of our listeners who work in emergency medicine settings, uh, pre hospital settings, I feel like we see them every single day. So that number sounds really, really low, uh, compared to what you and I witness. Um, so going back to all of these things, it doesn't matter what the type of the seizure is. The treatment is still the same, right? We're still doing the same things for our patients, right?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 5:55

100%. And, you know, in some ways, you know, you want to approach seizures like you're approaching resuscitation the way you're going to start with your a B's and C's. So you want to make sure you know that you have an open airway that your airway secure. Um, and also in Children, we always talk about positioning, positioning, positioning. You want to make sure that your patient is Who's seizing is in like a recumbent position. You want to have them on their side. So they don't bite their bite their tongue. Um, you want to have them in a safe place, but you want to check for that airway. Make sure to secure the airway, um, you know, make sure to look out for breathing. Seizures can be caused by metabolic disturbances. And one particular. Major causes hypoglycemia. So checking glucose is a quick way of figuring out whether this is a hypoglycemic seizure, and it's also a quick way of getting the management to resulting in cessation of the seizure, right? Because our ultimate goal is to stop the seizure. And so one of the things you want to do. with seizures is to make sure you check for a glucose. But I would argue that you want to focus on your a B's and C's first. You want to make sure that airway, um, is secure or is clear. Um, you want to make sure that the patient, you know, is breathing and might not be in a synchronized way cause they're actively seizing. Um, and, but one of the things additionally you want to check is, is the glucose. You want to check for hypoglycemia. So low glucose, um, which you could easily fix either from a, emergency department standpoint or from a pre hospital standpoint.

mohamed_1_11-18-2024_131805: 7:22

Yeah. And I, and I really want to kind of organize this. Uh, so let's just tackle this from two ends, from the pre hospital setting first, and then the hospital setting. Uh, so for our EMS folks out there, it's when they show up on a scene and you touch upon the most important factors, what they need to consider. Uh, but let's just go back a little bit. Let's just step back to history. What will be, let's say, assume the patient is stable. The child is stable. Uh, they're awake. They're talking to EMS. What are some of the important questions that our EMTs and paramedics need to ask, uh, bystanders or family about what happened?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 7:59

So in regards to history, you really want to know how long was the seizure, how long was the seizure like event, um, because that puts your seizure in different pockets or different categories and that helps in the way of management. You also, going back to the definitions we spoke about before, want to get a sense of whether this was provoked seizure or unprovoked seizure, meaning at the time did this kid have a fever, This could have an infection. Was there any trauma involved? There was, you know, was there any change in the way of medications or was this kid introduced to toxins that we're not aware of? So you, you want to know that you also want to know again, the characteristics of the seizure as much as possible. So was this child moving kind of unsynchronized body, entire body was flailing around or. Generalized what we call tonic clonic movements. Um, or was this like a focal seizure where we only have maybe one side of the body that was affected or one particular, um, extremity that was affected? Um, and and so all of those coalesce together can help you kind of synthesize what type of seizure it is. And best, best management practices. It is also helpful, you know, to, again, maybe if you can't figure out the timing, asking when the kid was last normal, you also want to know the frequency of events, right? So was this a one time episode or this multiple times and how many times within a certain period of time? So. How many times did these episodes happen over a 24 hour period, for instance, are all very helpful things to know. When did the kid last have something to eat or drink those are helpful for our folks later on. But I think the key aspects are. Was this provoked or unprovoked? What was the timing? What was the frequency? Um, and kind of going and, and is there any background history? So there's a, is there a history of seizures or is this what we call new onset? Is this the first time this kid has ever had an episode like this before? And if there is a history of seizures, you want to know the type of medications that that patient is taking, uh, for how long they've been taking that medication, and when was the last adjustment. One of the critical aspects of pediatrics that's different from adults is that kids are, they're growing. So, and, and medications for children are based on, is based on weight. Um, and so you want to make sure that. If there was a change in medication dosing, um, that hopefully it was recent and it counted for potentially a recent weight change. Now, as an EMS clinician, you're not going to break down all of those things. But understanding that if this kid has known to have seizures and they're on medications, like how recently have they been on them? And importantly, for all populations involved, have they been taking the medication? So have they been compliant with their medication? That will, can all help and guide in the, The overall management of of the pediatric seizure patient.

mohamed_1_11-18-2024_131805: 10:55

yeah, I feel like we always make, The job harder for the EMS folks, because what they do is the most important. Um, step or the most important part of taking care of the patients, which will ultimately influence what will happen to them in the hospital. So, you know, I tell you as a paramedic, I felt like it's really hard to try to get all this information that you just said, which are really important information at the same time as, you know, trying to take care of. Someone who is sick. So you're right. Absolutely. So we need to know all of this because it's important and it will impact what will happen to them in the hospital. But also just to go back to the basic EMS stuff that you and I are familiar with. So we have to make sure the scene is safe. If it's like a scene of, you know, domestic abuse, um, you know, maybe toxic exposure, also BSI, we have to wear our gloves, our mask, if there is maybe a signs of infection, uh, in the setting of a febrile seizure, so we have to wear a mask to make sure we also we don't get exposed to. And in addition to that, we have to collect, um, those information regarding medications or maybe prior seizure history. Ideally, if you know the dose, they'll be also good for the hospital team to know the type of anti epileptic agent and the dose as well. Um, because as you and I really know very well, is that a lot of our patient population, uh, either don't have access, prompt access to a neurologist, or maybe they were like lost, um, in contact with their primary care setting, or they don't have any access to medications. So is that your experience as well, Sylvia?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 12:38

Yeah And and going back to what you're saying of making things simple for EMS clinicians, you know I would say for pediatric seizures one, right? So 13 percent of all EMS calls are pediatric but interestingly enough 10 percent of those calls are seizure pediatric seizure calls And I say that to say that when you have low frequency high acuity It's hard to, you know, all the things that I've learned it out. It's hard to kind of sequence and organize them. And so what I would say was first would be to focus on the management. Management of the seizure and working on seizure cessation, uh, using anti epileptics, which we'll talk about in a little bit. Um, and then get as much of the focus history as you can, but I would, you know, focus on that scene, safety, airway, breathing, positioning, hypoglycemia. You know, and actually, I would say in conjunction and maybe a little bit higher. The research has shown is to start this, the, you know, seizure sensation with seizure management and then check a glucose and then do what you can with the focus history. But you're right. It is hard. Um, for various patient populations as far as access. As far as continuity of care. We see that a lot of pediatrics because kids cannot bring themselves to the hospital. They rely on their caregivers, and so sometimes that could be a barrier in the road. I will say the beauty This and podcasts like this is there is new evidence based medicine when it comes to this on the horizon. Um, the PDO study is out there and is the largest, one of the largest pre hospital NIH funded studies. And the whole idea around this is for, to simplify things for EMS clinicians and to create a standardized dosing for, uh, anti epileptic medications in the pre hospital field for children. So that you can say, okay, this is a six year old. I'm going to give X amount of. Let's say, uh, midazolam. And so it gets rid of a lot of the cognitive load. It helps to streamline medical errors. And most of all, it helps to benefit, you know, quality care of the patient. So that, that's an exciting thing that's coming around the corner. Speaking of, you know, trying to synthesize as an EMS clinician, there is a lot going on there.

mohamed_1_11-18-2024_131805: 14:51

Yeah, cognitive unloading is a very important thing for you. And I also in the ED, we do a lot of cognitive unloading with all of these apps. Now, do you recommend any specific app or resource? That EMS clinicians can actually use right now.

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 15:04

Yeah. So, you know, currently in the way, I think. The hardest part of seizure management is the medications, right? There are several types of medications that you can use in several routes. And so, uh, I think apps like, you know, HandHeavy, um, if you have a link based tape that, that can help you get the, not the volume that you need directly based on the weight, just to make, to unload that cognitive load and make the math easier. Because I think that's the hardest part in managing a seizure because we know that they're, you know, These drugs are not benign and they can lead to respiratory depression and even even failure in some cases and so trying to draw up that medicine trying to remember all the algorithms trying to figure out what the history is of the seizure can be a lot to do so it'd be it's nice to just Streamline things when it comes to actually giving the medication and knowing exactly what volume for exactly what age of child or even more importantly, um, estimated weight of child, uh, to stop the seizure. Um, so that's what I would suggest as far as an overall app to, you know, remember how to do seizure management. I don't have anything in mind there, but definitely a lot of your weight-based dosing apps that make it easier based on concentration and volume, I think can help. Um, in providing quality care in the prehospital field.

mohamed_1_11-18-2024_131805: 16:28

and for our EMS clinicians who practice in the state of Pennsylvania, the protocol for that is number 7007. And it lists to you the options, the benzodiazepine options that you can provide to pediatric patients and also the dosing. Thank you. Uh, so let's just, Sylvia, talk about that a little bit. Um, a lot of times, I'll be honest with you, I suck at getting IVs at kids, you know? Um, it's really hard. Sometimes they're moving or especially in this setting if they're confused or agitated. So what options in terms of routes of administration and what is an optimal option from your standpoint, from your experience, that you think that we should maybe, uh, use first beside the IV option in case that, you know, You know, was unaccessible or unsuccessful.

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 17:19

Yes. So the beauty of the pathophysiology of the pathophysiology that we're talking about in seizures is that there are so, you know, the best of diazepine group is, you know, our initial go to for seizures since cessation, uh, for both peds and adults. But in particular, in particular, pediatrics, What's nice is, you know, many of us, many of, maybe we don't know, there was a Rampart trial done for, in the EMS world looking at IM midazolam versus IV lorazepam, uh, corrected. So, what they found was that IM midazolam was non infected. Was a non inferior study and so is you could use I am Midazolam to help stop seizures and there were some kids that were Evaluated in that cohort and the study also showed that I am Midazolam helped with seizure cessation quicker than the other medications prior to coming to the emergency department. And that's kind of the pivot that PD dose is taking as well. The reason why I say that is, midazolam is a great benzo, otherwise known as Versed, Um, because you have, you, there are numerous routes that you can Administer the medication to stop seizures. So if you can't get the I. V. Or the I. O. N. Um, you can give it I. M. Uh, or intranasally. Um, and so, you know, that's very helpful when you have, you know, an actively flailing patient, um, when you're in a situation that's high acuity, low frequency, and you need to get the medicine in. Um, there is also, uh, rectal diazepam, rectal gel. A lot of parents may carry that. A lot of parents whose children have a known history of seizures. Um, so, this would not necessarily be the parent whose kid is seizing for the first time, but for those parents whose, you know, Children have are diagnosed with epilepsy. They may have tried to give some benzos in the way of diazepam rectal gel to kind of slow down the seizure. So that would be a history point to figure out. But so, in essence, you have potentially four routes. You have you have I. V. I. M. intramuscular. I. N. intranasal and rectally, um, and three of those routes you can use with one medication, meaning with dazzling and, um, Also known as Versed, so I think that's very helpful, especially with a population like the pediatric population to have in place.

mohamed_1_11-18-2024_131805: 19:44

And a lot of our EMS agencies do carry midazolam. Um, I felt like back in the days when I was a medic, there are a couple of agencies carried also diazepam, which is Valium. Uh, I think none here in Pennsylvania do carry lorazepam or Ativan. But this is, you know, some, some of the other options. It's just for completion sake. Uh, the doses are in the protocol as well, but Mendazolam is 0. 3 mg per kilo for the intranasal route. And you can give it for maximum, for the maximum of 10 mg or 0. 2 mg per kilo for the intramuscular route. And 0. 1 milligram per kilo for the intravenous route or intra osseous route as well. Um, do you have a preferred site for, IO placement? does it matter to you?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 20:33

Yeah, so interestingly enough, um, so I think traditionally and culturally we've done, um, the tibial route, but what we're, um, you know, um, What we're finding, um, in, in some research is showing that the distal femur route may be another option. Um, now those, I will, I will say that those studies are looking at pediatric cardiac arrest resuscitation measures in the way of using epi. Um, that I've read about, but we are starting to look at using the distal femur route in addition to the tibial route. Um, we rarely do the sternum or humerus. Uh, in children, but it is, it is still a route that can be used, uh, if nothing else. Um, but using the tibial, tibial route is what we traditionally use in pediatrics, but what I will say is that research is showing there might be other other means and ways, meaning the distal femur is quickly, uh, picking up a steam as far as an, as an IO route. For medications and pediatrics.

mohamed_1_11-18-2024_131805: 21:37

I'm comfortable with the IO with the tibia route for the IO placement. Um, I have done a few humoral IOs, but as you know, with, uh, younger children, you know, cooperation and also like high risk of, you know, Dislodgement if they end up moving around a lot, or you end up, you know, putting them on backboards or moving them back in a truck that can be at risk of dislodgement as well. Um, so we talked about dosing. So let's say now your patient, you're in a hospital setting. Um, got the doses of Versed and that would be the appropriate dose, but they're still seizing, um, either visibly like shaking or they're still altered. You mentioned earlier, Sylvia, that sometimes, you know, we risk, you know, we fear giving too much of benzodiazepine. Um, uh, because of the risk of respiratory depression or suppression. Do, does it matter, let's say if they're still seizing, do we re dose them? Do we do something differently or is there anything else that we have to think about, like maybe differential diagnoses?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 22:44

Yeah, I think, I think all of the above. I mean, I think the goal with seizures, um, is to stop them, right? Because we know that it can create harm if they are prolonged. Um, you know, from a physical manifestation standpoint and from the brain itself. Um, and so I, I think, you know, the answer, it depends if you have enough history to know that the cause of seizure is, is not from, Like the unknown. Let's say it's hypoglycemia. Then you want to act on that and give glucose right to resolve. But a lot of that deductive reasoning is hard to do in the E. M. S. Setting. Um, so I would say you want to do maybe a few things simultaneously in Children in particular, especially when you're worried about respiratory compromise positioning can go a long way. Um, so if the kid is actively seizing, you might want to reposition as well as get ready to administer another dose. Um, this might be a time if you weren't able to do a deep dive into the history and you as an EMS clinician still have access to the parents, this may be when you want to ask more questions related to the seizure about whether it's provoked, unprovoked timing to maybe help you. So maybe. The mom didn't or the dad didn't elicit that this was a trauma, but now that you know, no, it was a trauma. That being said, I would still give, continue to give additional doses of, of the benzos, unless it's something very clear cut, like this, this kid is hypoglycemic and we've given them, um, the management and the way of D10. And we're, we have a seizure cessation. Other than that, I would plan to redose. I would ask, continue to ask some more questions, and reposition, and do some of the other things that we would normally do. The other thing I want to say is, always reassess, to always go back through your ABCs, as the patient continues to see. So you want to check your airway again, um, and make sure it's clear. Because you may get a certain to a certain point where you may need to secure the airway. So you want to check that again. You want to go through your B. L. S. practice all over again. You want to check for breathing to see where you are, because it may be that you're leading down in a pathway where you need to secure the airway. And think about things such as, or airway protection such as, uh, intubation or placing a superglottic airway. So you always want to do a reassessment when a kid continues to cease or have seizure activity.

mohamed_1_11-18-2024_131805: 25:11

And one of my favorite adjuncts, uh, to closely monitor respiratory status is entitled CO2. What are your thoughts on that?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 25:19

A hundred percent. Um, I would say we don't use end tidal CO2 enough. for a lot of the pathologies that we deal with. Um, it can help with things like DKA and sepsis and things of that nature. But again, um, as we know, um, entitled capnography can give you a heads up on what may be happening, especially in the way of respiratory depression or potential respiratory failure so that you as an EMS clinician with minimal resources in your short period of time Can be able to prepare have enough time to prepare to potentially secure an airway or help out with breathing in the way of bag valve mask ventilation. So 100%. The other thing to think about is your airway adjuncts. Sometimes those are very helpful, um, in the way of seizures as well, um, especially if you have to, if you get to the point where you're doing bag valve mask ventilation, um, you want to make sure that you have a clear enough airway to be able to ventilate properly, and there's no resistance there. And so we want EMS clinicians to think early about these airway adjuncts, think early about potentially securing the airway. Obviously, I shouldn't say obviously, but in the way of looking at BLS, um, I didn't specifically say this, but you want to have your oxygen ready to go, be able to provide oxygen, particularly non rebreather 15 liters, um, when it comes to this, when it comes to seizure management.

mohamed_1_11-18-2024_131805: 26:40

Oh, yeah, absolutely. And for those of us who do also critical care transport, uh, you know, pre hospital nurses, pre hospital, uh, critical care paramedics, they also have access to venous gases. Uh, they have access to point of care labs, like, you know, sodium. Calcium, uh, they also have access to lactate. Um, what is the significance of lactate in someone who is seizing Sylvia? Um, I

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 27:07

Um, I mean, if it's high, it's, it's almost, It's not as great as capnography, but it gives you an indication that, you know, this, this patient may need additional, um, support in the way of airway, breathing, that has been going on for quite a while, um, so a lot of those parameters are helpful. In the way of the VBG, sodium, especially in children, especially infants, is very helpful. Um, at times, you know, Especially infant fed, fed babies. So infant fed babies, you have to create a, um, mix of formula versus water. And for some, some who are experienced or even in it, sorry, inexperienced parents or even experienced parents. Sometimes that ratio is off to favor more water. When this happens over time, when you have formula fed babies that have. More water than the formula content in the milk that can lead to a hyponatremia, which can essentially bleed to seizures. And this is something we see commonly enough in pediatrics that it is worth checking those things to help aid in the management of seizures. Because once you rectify the hyponatremia, you can help with the seizure management. In addition to the anti seizure medications.

mohamed_1_11-18-2024_131805: 28:24

Now, great points. Let's talk about, for example, that same patient that we just had in a pre hospital setting. Uh, EMS did great. They provided multiple doses of intraosseous midazolam. The patient is still seizing visibly and also, Uh, very altered and by the time they came to you Sylvia, uh, they were being assisted with ventilation via BVM, uh, internal CO2 is anywhere between 40s to 50s. At that point, EMS already tried multiple doses of IV benzodiazepine, the patient is still altered. Um, what will be your next step in the ED? Like what will be like now the, the care is being transitioned to you? Uh, we've

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 29:08

Yeah, so the care is being transitioned to us again. Reassessment and re evaluation is key, right? So you do have a history that it sounds like what we call status epileptic is where this kid could not stop them from seizing. so again, you want to, go over your A's and B's and C's. um, With that, you want to be able to secure the airway fairly quickly. What is also equally important is access. So you want to make sure that you have adequate access to provide additional lines of anti epileptic medications. So the first line of anti epileptic medications are usually the benzodiazepines, which we have already alluded to, in the way of the three routes of, uh, I am IV or IO midazolam and or rectal diazepam. Some folks opt to use IV lorazepam, which is also known as Ativan. Um, usually we do that for the first. two rounds of seizure cessation. When that doesn't work, we move on to other medications such as Fosbenetone, um, and Keppra, um, and so and give loading doses of those medications. So one, Because this is now become like a resuscitation like situation, we're going to secure the airway, right? We're going to do our a B's and C's. So we're going to secure the airway. We're going to continue bag valve masking until we can get our airway cart in order until we can get the right size tube or the right size. Superglottic airway. Um, make sure we have our respiratory therapist there. Make sure that our I. C. U. Colleagues are aware of this patient, uh, and begin the procedure of intubation in the way of rapid sequence intubation. Uh again now depending on the history and your records rapid sequence intubation Medic, you'll choose your rapid sequence intubation medicines accordingly For instance, if this was a like, a septic kid, you'd probably stay away from etomidate um, we still use ketamine and fentanyl and then Potentially more versa that you can use. I won't get into nuances of that, but the, the idea is that you're going to prepare for rapid sequence intubation of the patient while bagging. So that's first priority. Along with making sure that you have access, that the access that is there is maintained. If not, you're gonna get additional lines of access. Uh, usually we start with peripheral. If you can't get that, you can do IO. And then, um, not so much, central is another option, but usually we're pretty good with, with, being able to get IV or IO, um, access. Um, and so we, the EMS clinician has come in, they've given the first line of anti epileptic medications in the way of benzos. Now you're moving on to the second line of medications such as Fosbeni or a loading dose of Keppra. In addition to securing the airway. Um, and then, you know, if the patient continues to seize, then we begin to think about drips of, um, medications. You could either do another, a third line, um, uh, of medications or consider drips of, usually in the pediatric while we use, you know, benzos, um, and, and start a drip. Because again, the ultimate goal is to prevent seizure. So, and, and, and. In resummarizing what I said, first and foremost, this is a resuscitation at this point. So you want to make sure you secure your airway. Whether that be, um, endotracheal intubation or, uh, supraglottic airway, and you want to make sure you have, you regulate the breathing, you want to make sure you have access, um, and provide your second and third lines of medication. If those do not work, then you're dealing with a drip. In the interim, you're working with, at least at the children, at UPMC Children's Hospital Pittsburgh, we're working closely and succinct with respiratory therapy, who helps out with the airway, and our ICU colleagues to get the treatment. Our patient to critical care as soon as possible and and and to the, to the things that Dr. Hagahmed talked about in the interim, you're getting your, your, your labs, you're getting your VBG to further deduce what's going on with this patient, depending on the history, you may have to get head imaging in the way of a CT or fast MRI. But, of course, you're gonna want to secure your airway first. Before you do those other modalities in the way of status epilepticus, um, and so those are the, some of the things that you'll be doing, but you're going to do it in a resuscitation pattern, a, b's, c's, um, and then continue in with the seizure management medications.

mohamed_1_11-18-2024_131805: 33:42

Okay. So this is a really comprehensive, list, which I really appreciate that. Let's just break it down a little bit. So it, when it comes to. Induction and paralysis. Um, I prefer Tomidate and Roc. Sometimes I use Ketamine and Roc. Uh, what would be your go to uh, induction and paralytic agents for these patients,

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 34:06

Yep, so same thing as you said, so Etomidate and Roc. Roc, Roc is our paralytic of choice, um, so there's no use, changes there, um, but, you know, as far as your, your sedative medication, Etomidate we use unless, again, like I said, there's some hint or concern for sepsis, um, And then,

mohamed_1_11-18-2024_131805: 34:28

And that sepsis is because of the renal

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 34:30

the renal

mohamed_1_11-18-2024_131805: 34:31

Is that

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 34:31

and how it affects blood pressure. Um,

mohamed_1_11-18-2024_131805: 34:34

it really real in the pediatric population? Because I know there have been multiple data regarding adult population and that Questionable, maybe, um, about the adrenal suppressive effect of etomidate. Is it the same for PEDs or?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 34:48

I don't, I don't think we know enough about PEDS, but I know that culturally we do, anecdotally and culturally, unfortunately, we do stay away from it for the concerns of what you're saying in the way of adrenal, uh, suppression. And so, that's, that's what we do currently. I don't know if the evidence fully supports that that's where we are in kids. I think there's more to be seen in that area. Um, same with ketamine. I think we've we've been able to debunk the, um, TBI myth of, you know, increased intracranial pressure and concerns of use of ketamine. And, you know, in a lot of These neurologic pathologic cases, ketamine can be extremely helpful in, you know, in it. So not only is it not harmful, as I think the literature has come out to debunk, that it is not harmful in the way of increased ICP, especially in traumatic brain injury cases, um, but it is actually helps from a neuro perspective. Standpoint. And so we tend to use ketamine as well. Ketamine and Roc. And like I said, when it comes to our paralytic though, we stick to to rocuronium.

mohamed_1_11-18-2024_131805: 35:55

Yeah, I mean, I mean, I read so many interesting papers about that in a setting of, uh, status epileptic case or seizure management, which, you know, can, I mean, as we all know, it's an NMDA antagonist. And there's a role for glutamate and NMDA receptors, um, in, uh, children with seizures that is, like, this either overproduction of glutamate or, uh, hyperactivation of these receptors, uh, the NMDA that actually ketamine can act upon and help eventually, um, in terms of post, uh, let's say you said, like, the anti epileptic agents, Um, I guess let me just step back a little bit. So you intubated them successfully, they're now intubated, what will be your choice for a sedative agent? Do you also use Propofol the same way we use in adults or you use something different?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 36:48

we personally don't use propofol. Doesn't mean you cannot use propofol. Again, some of these things, you know, I think is institutionally based on what you use, but not necessarily evidence based on what we use. And so in our emergency department, we don't use. Propofol per se. Um, but you could use, um, that is a good question. I think it's more of a logistical issue that we have not been approved to use propofol in our ED space. Um, I don't know, I don't think that's necessarily an evidence based decision. Um, I think it's more based on historical principles, but we, even for our sedations, we pretty much use ketamine, um, for our sedations.

mohamed_1_11-18-2024_131805: 37:28

for sedation. So what, what, what's, what's your doses there? I'm curious now.

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 37:33

Um, so for our ketamine doses, we do about 1.5 to two per kilo. Um, you know, maxes depend, you know, usually about to, to a hundred. And then we do, if we're talking about sedation, we do 1.5 to one for, you know, the initial, um, loading dose. And then we do one one milligram per kilogram, one milligram per kilogram per subsequent, uh, doses. So we do about one milligram per kilogram of ketamine is what we use. To a maximum about

mohamed_1_11-18-2024_131805: 38:05

and then you mentioned, yeah, you mentioned the ketamine, but do you also add in any type of, uh, uh, analgesic as well, like fentanyl or anything like that, or just, you just stick with the, with the

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 38:14

if we're talking about sedations or seizures.

mohamed_1_11-18-2024_131805: 38:17

sedation, sedation,

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 38:18

Yeah, sedation. That is. I would say user dependent or physician dependent. We usually just use the ketamine. Um, just because, you know, the history of having used the two types of medications, right, ones that activate the or deactivate the pain receptors in the way, for instance, fentanyl and Versed that helps, you know, With sedation, uh, there's more concerns for side effects or, you know, drug effects of both medications. And so we pretty much streamlined the ketamine. It works fairly well. Um, sometimes depending on what we're Using this what we're sedating for. Um, let's say if it's something that requires a musculoskeletal in a way that you need relaxation of the muscle, we might add, uh, Valium, for instance, in a way to help additionally with muscle relaxation and then Ketamine to sedate. But a lot of times we solely use Ketamine now in the. sedation suites. They use things like propofol, dex, dexamethamidine, um, and sometimes for quick procedures they do nitrous.

mohamed_1_11-18-2024_131805: 39:30

That's very interesting. And, uh, you mentioned the anti epileptic agents. Do you, is your first go, um, agent of choice, is it always, uh, libitoricetam or Keppra or do you just jump with Fosfenitoin first?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 39:46

Yeah, so let's say this patient presented to the hospital, didn't present via EMS, and has not received any medications. Our first line are benzos, benzos, benzos. Um, and depending, I prefer, um, midazolam, um, Um, because of the pharmacokinetics and the timing of it, you have less in the way of stacking. What do I mean by stacking? So lorazepam, also known as Ativan, can sometimes When you're looking at the pharmacokinetics and the pharmacodynamics of the timing can seem not to be working until it starts to work. And so for fear that the medicine is not working fast enough, people give an additional dose, an additional dose, an additional dose. And then once all of those doses have kind of culminated, it can end up in a respiratory depression type of condition. Uh, I think verse said, as far as the timing of onset kind of as well spaced out for you to be able to calculate how well it's working in a certain period of time. Um, and so the initial, the first line of, of anti, sorry, the first line of anti seizure medications that we use are benzos, uh, can be a midazolam and or lorazepam are the two main choices that we use. Again, diazepam is kind of falling out of favor. And, and as you can imagine, um, you know, via the rectal route, that can be a little bit complicated for a child, but, um, You know, in cases or limited resource limited cases where you're not able to get it in any other way, that might be a quick way to get it done. Um, second line is when we talk about phospheny and Keppra, we do usually one or the other 20 milligram per kilogram of phospheny, uh, 60 milligram per kilogram of Keppra. Or 60 milligram per kilogram of Keppra loading dose. Um, and then after that, usually then we start talking about the resuscitation aspect of things where we need to secure an airway or does this patient need to go on a potentially like a midazolam trip or a sedative trip, uh, to stop the seizures. And now, when I talk about the first line of anti seizure medications, the first line of medications we may give several times, meaning 1, 2, 3, 4, 5, Usually two or three times, right? And so by the time we get to the second line, um, We're usually kind of, I don't want to say done, but then we're usually at a point of make or break either you've broken the seizure and we've moved on or you haven't broken the seizure. And now we're in the critical care space where we're talking about drips, if that makes sense.

mohamed_1_11-18-2024_131805: 42:25

Yeah, so just, uh, not to spend time when it comes to the intervention. So to summarize Benzo's first line, and then anti epileptic agents with either IV Keppra, phosphonatoin, and then you touch upon like the other stuff like about peroic acid. And then, uh, eventually if they fail these things and they're still having signs of a non convulsive status epilepticus, obviously by then you need an EEG to confirm that. Then you start them like on phenobarbital and ketamine drips and, and all of these things. So that sounds like a, a, a kind of, uh, the pathway you're, you're approaching. Is that correct,

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 43:04

That is correct. Yeah.

mohamed_1_11-18-2024_131805: 43:05

Now, when it comes to your, um, ED evaluation, uh, can you just share with our listeners some of the differential diagnoses you are worried about in these sick children that are now intubated and there are basically in status epilepticus, like what are some of the things you worry about and how do you manage them?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 43:23

Yeah. So again, I think we, we talked about some of these things in the way of infection, so not only just meningitis, but encephalitis, right. Um, febrile seizures, febrile seizures sometimes can, you know, can, can Lead to not having a seizure cessation and can lead to intubation. In those cases, you may want to make sure that the child doesn't have an infection of some sort. Trauma is another thing that we think about again. Metabolic disturbances. Um, and remember with children, metabolic disturbances are pretty significant, especially in the infant category. We gave the example of the infant formula, but also in the way of potential genetic disorders. Um, you know, things like, you recycle disorders, taking back to biochemistry, um, some of these other disorders where. Either your glucose is off or your nitrogen cycles are off and parents may not be aware of that Um oncological causes in the way of tumors um, and then we have not talked about this, but the Technologically dependent children in the way of children who have things like vp shots So hydrocephalus can be another thing that you may not see as much in the the adult world that can also cause and hydrocephalus can be caused by many things, meaning an excess of CSF in the cerebral space, um, that is not able to be drained in the proper way and can cause increased intracranial pressure. Um, so those are just Some of the things that we think about and toxins is a big one, right? So, um, we know that especially in the younger ages, infant to toddler age, that kids get into a lot of different things. One of the particular toxins that we've been seeing an increase in seizure activity. is, um, THC gummies. Um, and kids getting into their parents supply of either edible, edible marijuana or THC gummies. Uh, that can lead to significant Um, lower the threshold for seizures and lead to significant seizure activity, um, un, unconsciousness, um, and obtundedness really. And so we're seeing a surge in, in those and we have, we have quite a few kids that come in, um, with what we think are unprovoked seizures and end up having, uh, to be, um, T, THC related. Seizures. So toxins are another big one that you want to think about, uh, in the pediatric population as well.

mohamed_1_11-18-2024_131805: 45:56

Sylvia, I still vividly remember this case. I had a 14 year old female, um, a couple of years ago, um, that was when I was practicing in Texas, but came in with, uh, multiple episodes of seizures. So she was in status. And, uh, EMS did what they were doing, did a great job with giving benzodiazepine. But, uh, you know, what I found that she was pregnant, again, uh, so she was basically a clam tick, right? This is eclampsia. So what she needed was IV magnesium and, you know, tons of loads of magnesium and, um, we especially saw this, um, in our hospital system in Texas where, you know, a lot of, uh, mostly immigrant population didn't have good access to care. So, um, it's important to remind our listeners to expand your differential diagnoses and taking care of a child doesn't mean that. That they're not pregnant, you know, always make sure that you ask about these things or ask about, you know, when they began to have periods and, and consider that if that's not the case, if you've given benzos, tons of benzos is still seizing, like you said, infection, metabolics, uh, pregnancy in, uh, any woman of childbearing age, and also, like you mentioned, trauma and specifically non accidental trauma, right? We have to worry about that stuff as well. Um, last but not least, I would tell you about, like, I think maybe something that I would like to do better at is having these family discussions when it comes to, um, seizure prognosis and outcomes, um, especially the ones that are stable when they come to you stable, Sylvia and AD, and you know, you're going to discharge them, obviously you're going to discharge them with, um, Follow up with neurology in the clinic, but how do you approach these family discussions regarding recurrence of seizure? Let's say in the setting of a febrile seizure, uh, having one episode of febrile, febrile seizure. Does that mean they're going to seize again soon? Does that mean now they're going to have a diagnosis of epilepsy? How do you talk to family about these things? So,

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 48:01

first is I acknowledge that it's scary. Right. I mean, you know, to kind of glance over it. We know, um, you know, as, as, as medical folks or physicians that, um, the prognosis is fairly well for febrile seizures. But we, what we have to remember is that from a parent standpoint, it's one of the scariest things that could ever happen to a person's child. And so I acknowledge that it is a scary thing that has happened. Um, and then we talk about, you know, what, what, what is a febrile seizure? So, um, We alluded to this earlier, you know, febrile seizures happen from children ages about six months to five to six years. So that brings about the point if you have a kid who's seizing who's less than six months And and they're febrile or greater than six years in febrile You might want to take put febrile seizures lower on your differential so you don't miss something else So I just want to put that caveat out there um Secondly, we go over supportive care and fever management and how with febrile seizures, you know, I talk about fevers almost as thermostats that are alerting the body that there's a germ inside there. There's something going on inside. And sometimes with that surge. In the temperature, you have a surge in electrical activity, which results in febrile seizures. Key key things to know about febrile seizures is that, unlike other types of seizures, Children come back to their baseline fairly quickly. So, you know, maybe for a few seconds they have tonic clonic movements and they're moving around, but they're able to wake up, look around. In some cases, they're able to eat, play, do the things that they normally do, which is very different than A non febrile seizure where you have what we call the postictal period where the child is sleeping, uh, or sleepy, I should say. And so, I, you know, explain to the parent that as scary as this is, this is, the seizure is in relationship to the fever and how fast it has, the fever has gone up. Not so much to say that this is Um, that the child will have a history of seizures or history of epilepsy, and that we see it a lot. So, is a child allowed to have more than one febrile seizure? 100%. And so if a child comes in with another febrile seizure that meets simple febrile seizure criteria, and we'll go over that, Um, do we give the same instructions? Yes, we do. So, uh, fever care, supportive care, And you're able to go home and your child is okay. Now, a simple febrile seizure is a seizure that happens related to a fever. Again, the thermostat or the temperature is shot up real high. That has caused a surge in electrical activity. Um, but a simple febrile seizure is one that has lasted less than 15 minutes. It is not focal. or, um, and it has not happened more than once in a 24 hour period. So when we're talking about febrile seizures in this case, I'm talking about simple febrile seizures. Um, in complex febrile seizures, they meet the opposite of everything that I said. So you have a fever, I'm sorry, you have a seizure secondary to fever that has shot up pretty quickly, caused a surge in electrical activity. But now this fever has either lasted greater than 15 minutes. It's focal or you've had more than one. In that case, we usually, uh, do lab work in the emergency department and, and place EEGs on the children, child, and bring them in overnight for observation and have them work with a neurology or be taken care of by our neurology team. So that's, that's a little bit different. Um, so in the case of febrile seizures, they are pretty, quote, they are safe. In the way that, you know, kids can go home. We're not concerned about a sequelae. We're not concerned about quote unquote brain damage in those children. It's more related to the fever itself. In complex febrile seizures, we have a little bit more investigation and digging to do. And so usually those kids get EEGs and stay in the hospital.

mohamed_1_11-18-2024_131805: 51:58

Nice. And I, um, also found this evidence, um, to consider when counseling families regarding febrile seizures. large Danish study of up to 2. 1 million patients. The lifetime risk of febrile seizure was 3. 6%, so 3. 6 percent of this 2. 1 million patients. And the risk of having a second febrile seizure was 23%. The baseline risk of epilepsy in this population was 2. 2%. Um, and 6. 4 percent after a first febrile seizure. Now, interestingly, um, Sylvia, I know we give like antipyretic agents, you know, acetaminophen or ibuprofen for fever, but the, um, obviously they're good for comfort, right? But until recently, there was no convincing data that antipyretic agents, i. e. acetaminophen or NSAIDs, Make a further seizure less likely. So, I found this randomized controlled trial in Japan. So, the number of patients was about 438 patients. that showed that a second febrile seizure, so a second seizure, occurred in 22. 6 percent of patients who were not given acetaminophen versus only 4. 1 percent of children who were. So I think also the other part of the, uh, education piece for families Is that it's okay to give these children's antipyretic agents and actually encourage them to do so. Um, but also like, you know, you have to alternate. So, you know, what is your, um, advice regarding these, uh, like how to provide these medications? Do you tell them to alternate this? And what do you tell them exactly? Um,

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 53:51

Yeah, I tell them you have, you know, you have two main choices of antibiotics, which is acetaminophen and ibuprofen. Um, you know, both work on, you know, both work to bring the fever down, hence the antipyretic. But ibuprofen, you know, does a little bit more when it comes to the anti inflammatory receptors. And so, and inflammation can lead to pain. And so, what I remind parents, you know, is that children cannot, Usually vocalize what's going on with them. The aches and pains, my allergies, they may be feeling when they're sick, especially when they have fever. Um, and so I think it's good to have both on board. While acetaminophen is a great fever reducer, it's not, may not be as a great of a pain reducer. And so alternating the two is a great. great. thing to do to kind of provide supportive care for your child with a febrile seizure. Now, Acetaminophen is given every 4 hours, and Ibuprofen is given every 6 hours. What I reassure parents is that, although both types of medications reduce fever, They work on different pathways. So if you were to give both medications, you're not quote unquote overdosing your kid on antipyretics. I describe them as cousins. So it's not like you're giving a double dose of acetaminophen or a double dose of ibuprofen. So I will give usually give an example. Let's say and and I say you can start, you know being a parent and the complexities of timing and being a parent. I say it's okay to start. Let's, you know, you can give your acetaminophen at noon, and you can give your ibuprofen at noon. Again, we're not overdosing. We're two different pathways. The next dose you're going to give is at 4 p. m., and that would be your acetaminophen, and the next dose of ibuprofen you would give would be at 6 o'clock, and then you kind of time from there. So your acetaminophen would be every four hours, so that it'd be 4 p. m., then 8 p. m., and your ibuprofen would be 6 p. m. And then midnight if your child is still up and febrile. The other thing, you know, in pediatrics that we really want to stress to parents for parents to understand is not having what we call fever phobia again, you know, the way I described fevers is it fever is a way of the immune system, allowing. the body to recognize that there is an intruder in the way of some type of germ, whether bacteria, virus, parasite, right? And so we don't want to get caught up in so much in the fever or be scared of a fever. So I say that to say, if the child is no longer febrile, not necessarily recommending to give an antipyretic. Um, if the child is febrile, go ahead and give the antipyretic. In the time described. And so, um, I think that's a good balance of kind of managing any kind of febrile illness, to be honest with you.

mohamed_1_11-18-2024_131805: 56:39

This is probably the best advice, um, and I appreciate you for sharing this because I feel like, you know, I agree with you. Like a lot of our parents, um, that we see in AD tend to be like, you know, really afraid of their children, their kids having fever. So we have to remind them that this is actually a natural response from the immune system. And they're actually building a stronger immune system. I really appreciate this discussion, Sylvia. This has been great. Uh, this has been, uh, comprehensive, uh, informative, and also enlightening for me. And I'm going to do my best to summarize it within the next, hopefully, one minute, one minute or two minutes maximum.

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 57:13

a lot.

mohamed_1_11-18-2024_131805: 57:14

So, that's going to be the hardest

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 57:15

There's a lot going on.

mohamed_1_11-18-2024_131805: 57:17

feel free to interject. Uh, so, pre hospital management of, um, uh, children with seizures. Basically, it's all around maintaining the ABCs, well, scene safety first, BSI, and then you have your patients and managing their airway, maintaining their ventilation, encouraged with entitled CO2 to closely monitor that as well. Making sure there's no signs of trauma and then C collar mobilization if needed. Trying to get as much information as possible from the parents, from the scene, from the bystanders that would help us in the hospital to further come up with a diagnosis and the appropriate management. And then they have to come directly or they have to, uh, jump directly to management of the seizures. So with ibuprofen, ibuprofen, ideally IV. Uh, IO or intramuscular agents, like we talked about where they come to you to the hospital, uh, you stabilize them if they need an airway, you, uh, obviously go ahead with controlling that and then you initiate anti epileptic agents, Keppra, Phosphatidone, and all this stuff. And then. Trying to make sure you're not missing an infectious ideology or trauma, bleed, uh, you mentioned patients with VP shunts. Um, you also mentioned, um, managing like expectations by family as well. I think what I'm going to do is I'm going to try to summarize this in a document. It's going to be included in the podcast as well, and I'm also going to include, um, these two studies that I mentioned in addition to the data, uh, and instructions that you can provide to family members that Sylvia just mentioned. Anything else would you like to add, Sylvia?

dr--sylvia-owusu-ansah_1_11-18-2024_131805: 59:02

two more things, pre hospital wise, always transport a seizure patient, regardless if the seizure has stopped or not, make sure they come to the hospital. Secondly, we didn't really talk about the babies less than six months, but just quickly, they have a different, they can have different types of seizures known as infantile spasms where they may be smacking their lips or having a certain types of twitch. Any infant who's not acting normal needs to come to the hospital, whether that is via an EMS clinician or via a parent, all those kids need to be evaluated. Those types of seizures, neonatal seizures and infant seizures are treated differently, usually with phenobarbital. So just wanted to add those two things. But Mo, this has been great. Congratulations on eMERGE. Thanks for having me here to talk about pediatric seizures and, and bringing the evidence based medicine. Thanks for, for having me.

mohamed_1_11-18-2024_131805: 59:54

Sylvia, I'm not going to let you get away that easily. You're definitely coming back for more discussions. And, uh, I definitely appreciate this enlightening conversation. And I hope that would also benefit our listeners. So please take care and then until the next episode, have a good one..