I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Sunday, 26 January 2014

Seizures in Children

There's lots of information on seizures, and it can be hard to know the differences in management between children and adults. Most of the information says the same thing - just in different ways. There's a podcast from BMJ Learning and information from EMBasic. Nothing really covered generalised seizures in children, so I actually looked at a paper text book to get some information on seizures in children - the "Sunflower Book" as we called it at medical school! 

A seizure is defined as "a clinical event in which there is a sudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge. Seizures may be epileptic or non-epileptic". 

There are lots of differential diagnoses for seizures, and a careful history will help you elucidate the true cause. 
Febrile Seizures - see later
Paroyxysmal Disorders - "funny turns"
Breath holding attacks - child cries, holds his breath, and goes blue. Sometimes children loose consciousness. Behaviour modification + distraction may help.
Reflex anoxic seizures - occur in infants or toddlers. May have a first degree relative with a history of faints. Commonest triggers are pain or discomfort - minor head trauma, cold food (ice-cream or cold drinks), fright or fever. Triggering event, then child becomes pale and falls to floor. May have a generalised tonic-clonic seizure. The episodes are due to cardiac asystole from vagal inhibition. Seizure is brief and the child rapidly recovers. Ocular compression under controlled conditions often leads to asystole and paroxysmal slow-wave discharge on the EEG.
Syncope- faint if in a hot or stuffy environment. Clonic movements may occur.
Migraine- paroysmal headache involving unsteadiness or light-headedness as well as visual or GI disturbance. These symptoms may occur without the headache.
Benign paroxysmal vertigo- recurrent episodes of vertigo, 1- several minutes + nystagmus, unsteadiness or falling.
Cardiac arrhythmia-  prolonged QT = rare
Tics, daydreaming, night terrors
Self-gratification- genital stimulation for comfort, rather than sexual gratification.
Pseudoseizures / fabricated / induced illness: eg adult injecting insulin
Paroxysmal movement disorders - well-circumscribed episodes, genetically determined, no loss of consciousness.

Incidence 0.05% and prevalence 0.5%
There are lots of different types of epilepsy, depending on which part of the brain is affected. Not all epilepsy is tonic-clonic.
 - Frontal seizures - motor or premotor cortex. May lead to clonic movementsAsymmetrical tonic seizures can be seen, which may be bizarre and hyperkinetic.
- Temporal seizures- strange warming feelings. Lip-smacking, plucking at clothes, automatism.Consciousness can be impaired.
- Occipital seizures -distortion of vision
- Parietal lobe seizures - contralateral dysaesthesias or distorted body image

Epilepsy Syndromes
- West Syndrome - flexor spasms
- Lennox-Gastaut syndrome - drop attacks
- Childhood absence epilepsy

Take a full and careful history. You need to do a full and careful examination - to reassure the parents if nothing else. Most patients can be discharged with outpatient follow up and very careful advice:  cycling in traffic, swimming alone, deep baths, contraception + pregnancy and driving.

Status Epilepticus

The definition of status is, as always controversial. The "traditional" definition is a seizure that lasts 30minutes or more or clusters of seizures lasting for more than 30minutes with no recovery in between.

In 2008, the Neurocritical Care Society introduced a new definition for Status Epilepticus because (to quote boringEM)…
"- By 5 minutes a seizure is like the Energizer Bunny: it keeps going and going… and is unlikely to stop.
 - The brain is frying: 30 minutes (the old definition) was too long because neuronal injury/pharmacoresistance likely occurs WAYYYY before 30 min of continuous seizing."

"Status Epilepticus: Continuous seizure activity for greater than 5 minutes or the occurrence of sequential seizures over a similar period without recovery of consciousness between seizures"

It can be caused by:
 Febrile illness
 Infection (particularly meningoencephalitis)
 Metabolic derangements (including hypoglycaemia & electrolytes, eg. hyponatraemia)
 Medication change

The NICE Guidelines have a very sensible summary of treatment that is very clear, although it doesn't mention PO/Buccal midazolam. The College of Emergency Medicine has some excellent local charts, including one from Manchester, that has lots of good information on it that is well presented.

Benzodiazepines are always the first, and second choice. We can give benzos by so many routes that we don't need to get stressed about gaining IV access. If we don't manage to gain IV access, paraldehyde is still in the paediatric guidelines. Unlike the adult guidelines, the paediatric guidelines are still very clear that we don't give phenytoin if the patient is already on phenytoin - maybe because we assume children are more likely to be compliant?

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