Extern conference January 3 rd 2008. Case A Thai 2 years 10 months old girl Chief Complaint...

Extern conferenceJanuary 3rd 2008

Case

A Thai 2 years 10 months old girl

Chief ComplaintGeneralized tonic clonic

seizure 15 minutes prior to arrival

History of present illness 2 days ago, She had high grade

fever and loss of appetite. Her mother gave her paracetamol and tepid sponge. She vomited food when she ate.

A day before, She had high grade fever as well and passed watery stool once. Her mother took her to a hospital.

History of present illness Doctor at a Hospital nearby her

house gave her paracetamol, simethicone, motilium, amoxicillin, pseudoephridine and ORS.

After she came back home she still had high fever and got seizure.

During the seizure, her arms and legs was stretch out and no clonus, eyes was stared up. Duration of Seizure was 2 min. After the seizure she slept for one hour.

History of present illness Her mother brought her to Siriraj

Hospital. At ER, after the seizure she awoke

without focal neurological deficit. The doctor at ER administered aspirin

syrup and discharged her from ER. The same day, 15 min prior to arrival

she had recurrent seizure. The pattern of seizure was the same as the first time, however she also had clonic movement of her extremities.

She came back to Siriraj hospital and was admitted.

Past medical history She is a healthy girl. She had two episode of

seizures when she had high grade fever at the age of 1 year old. She did not hospitalization and no anticonvulsant agent was administered.

Family History

Her father had an episode of seizure with high grade fever when he was a child.

She had no family history of epilepsy.

Others history

Development: normal Vaccination: Complete according

to EPI Nutrition:

Rice for 2 meals with soy milk 6 boxes/day

Drugs & allergySulfa group hypersensitivity No drug used continuously

Physical Examination Vital Signs T 38 °c PR 136 /min

RR 36 /min BP 119/57 mmHg BW 18.7 Kg (> P99th) Ht 96 cm (P90th-97th)

Weight for height = 133.57 % General Appearance

Alert, active, no sunken eye balls, not pale, no jaundice, no skin lesion, no cyanosis, no clubbing of finger, capillary refill < 2sec

HEENT mild injected pharynx and tonsil, tonsils enlargement 3+, TM not injected

Physical Examination CVS regular pulse, normal S1 S2,

no murmur RS Normal breath sounds, no

adventitious sounds Abdomen Soft, mild distention,

not tender No hepatosplenomegalyActive bowel sounds

Physical Examination NS E4V5M6, good

consciousness, all CN were intact, fundoscopic examination can’t evaluate (uncooperative)

normal muscle tone, motor power grade 5 all extremities, no stiff neck

Investigation

Complete blood count:Hb 11.9 g/dl Hct 36.4 %

MCV 70.9 fLWbc 20,420 /mm3 N 86.9 % L 5.4

% M 5.3 % Eo 0.4 %Platelet 240,000 /mm3

Peripheral blood smear: normochromic microcytic RBCsplatelet : adequeteWBC : neutrophils predominate,

no band form, toxic granule 1+

Investigation

Urinalysis:pH 5 Sp.gr.1.015Albumin neg Sugar neg

Acetone neg Rbc 0-1 /HPF Wbc 0-1 /HPFbacteria 1+

Investigation

Na 134 mmol/L K 3.7 mmol/L Cl 101 mmol/L HCO3 19 mmol/L Magnesium 2.2

mg/dl Corrected Ca 4.8 mg/dl

Discussion

Problem List

febrile seizure which lasted 15 mins and 4 hrs PTA High grade fever, watery diarrhea, vomiting for 1

day Family Hx of febrile seizure in the young : His

father Hx of febrile seizure at 1 year old Mild injected pharynx and tonsils Tonsilar enlargement 3+

Differential diagnosis

Febrile seizure CNS infection Intracranial hemorrhage Metabolic causes Shigellosis

Febrile seizure

Simplefebrile seizure

Complexfebrile siezure

Febrile seizure

Simple febrile

seizure

Complex febrile seizure

Lasts less than 15 minutes

Occurs once in a 24-hour period

Generalized

No previous neurologic problems

15Lasts minute s or l onger

O OOOOO O OOO OOOO - - once in a 2 4 hour

per i od

Focal

Patient has kno wn neurologic probl

ems, such as cerebr al pal sy

CNS infection

Meningitis Encephalitis Brain abscess

Intracranial hemorrhage

Subarachnoid hemorrhage Peri/intraventricular hemorrhage Subdural hemorrhage

Metabolic

Hypoglycemia Electrolyte imbalance

HypocalcemiaHypomagnesemiaHypo/Hypernatremia

Shigellosis

History of acute gastroenteritis with moderate dehydration

Toxin induced seizure

Diagnosis


Acute gastroenteritis with moderate dehydration

Febrile seizure

OO OOOOOO OO . et al. : OOOOOOOO OO O O ildren. Pediatr Clin N Am 2006; 53 (25

7 277– ). Michelle D. Blumstein et al . : Childhood Sei

zures. Emerg Med Clin N Am 2 0 0 7 ; 25

(1 0 6 1 –1 0 8 6 ).

Febrile seizure

C onvulsion that occurs in associati on with a febrile illness in children

between 6 months and 5 years of age in the absence of an identifiab

le cause . Febrile seizures are the most com

mon type of seizure in young child ren, with a 2% to 5% incidence of c

hildren experiencing at least one s eizure before the age of 5 years.

Febrile seizure

Simple febrile

seizure


Lasts less than 15 minutes

Occurs once in a 24-hour period

Generalized

No previous neurologic problems

15Lasts minute s or l onger

O OOOOO O OOO OOOO - - once in a 2 4 hour

per i od

Focal

Patient has kno wn neurologic probl

ems, such as cerebr al pal sy

Febrile seizure

The peak age for febrile convulsi ons is between 18 and 24 month

s. The exact pathophysiology is un

known , but it seems that a fever lowers the seizure threshold.

F amily history of febrile seizures present in 25% to 40% of childre

n with febrile seizures.

When to do a lumbar puncture?

When to Do a l umbar puncture?E 1very child < year OO OOO O OOO

a febrile convulsion.POOOOOOO OO O OOOOOOOO OOOOO OO

d symptoms. OOOO OO OOOOOO , O f LP is not perfo

rmed , the paediatrician is advised to review the case within a few

hours.

Investigation : LP

HKJ Paediatr (newseries)-2002714315; :

1

When to do an imaging study?

Not necessary in most cases,but exceptions in a child withpapilledema cranial nerve palsies (eg. 6th ne

rve palsy) other persisting focal neurologi

cal signs (eg. hemiparesis) marked depression in mental statu

s

Investigation : Imaging


1

R arely indicated in the manag ement of a simple febrile conv

ulsion Complex febrile seizure

Investigation : EEG


1

E lectrolytes and sugar in a chi ld who is drowsy or

dehydration T oxicology screening if

suspicious

Investigation : Blood chemistry


1

Acute management : general Same as other type of seizure Maintain a clear airway (ABC!!!) Give oxygen if available Apply suction for nasal or oral secretio

ns if facility available - Place the child in a semi prone position Protect the child from injury Loosen clothing or remove excess clot

hing Monitor vital sign

HK J Paediatr (new series 2002) ;7 -143:151

Acute management : terminate seizure Benzodiazepines are the first drug of cho

ice for persistent seizure activity. Diazepam is the most common drug

used - 0205administer rectal diazepam . . mg/kg

/IV dose is 0.3 mg/kg/doseThe same dose can be repeated every 10 to

30 minutes to a total of 3 doses, if necessary Lorazepam IV form is not available in

Thailand


Observation for several hours after a febrile convulsion

Patients with a simple febrile seizure may be safely dischar

ged to home with parental reassurance and seizure education .

F ollow up care

Acute management

C omplex febrile seizure S uspicious of possibility of me

ningitis and encephalitis A ge < 18 months A nxious parents or inadequat

e home care

Hospital Admission: indication


Management : fever Identify cause of fever S ponging with tepid water Antipyretics

Paracetamol 10-15 mg/kg/dose orally every 4-6 h

Paracetamol 10-15 mg/kg/dose IM form if oral route cannot be administered


Recurrent Febrile ConvulsionsManagement Intermittent prophylaxis Continuous prophylaxis


Antipyretics and tepid sponge. Diazepam prophylaxis seems to be eff

ective in reducing the recurrence rate. S uggested doses for prophylaxis

0.5 mg/kg administered orally, or recta lly every 12 hr whenever the rectal tem

perature is > 38.5 ํC M aximum of 4 consecutive doses

Side effects of diazepam ataxia, lethargy and irritability

Management : intermittent prophylaxis


- Long term Anticonvulsant ProphylaxisP henobarbitone or sodium valproateCurrently N ot advise due to

• No definitive evidence that anticonvu lsants can prevent later epilepsy

•S ide effects of medicationsO nly use in highly selected case

• based on clinical circumstances and t he judgement of the benefit and its s ide effects

Management : continuous prophylaxis


Recurrence Risk of Febrile Convulsion Risk of recurrence is~ - 25 30% Major predictor for recurrence of febril

e convulsion•E arly age of onset

Other predictors;•Duration of fever before febrile seizure

•Temperature at onset of seizure•Family history of febrile seizure, Prolonged seizure

Prognosis and outcome


Will the patient have epilepsy in the future?

Risk factor for epilepsy

C hildren with febrile seizure have only a 1% to 2% lifetime risk

R isk factors for epilepsy F amily history of epilepsy C omplex febrile seizure U nderlying neurologic disorder

If two or more of these risk factorspresent , the future risk of developing ep

ilepsy is 1 0 %. G eneral population have 05 1. % to %

lifetime risk of devel opi ngepi l epsy

Intellectual Deficit ? I ntellectual outcome is good Risk of Intellectual Deficit

P - re exi sti ngneurol ogi cal or d evelopmental abnormality

T hose who developed subsequ ent afebrile convulsions

Reassurance and education is thus very important.

Information to be provided toparents:

Parental education and reassurence

What should I do if my c hild has

a convulsion in the future?

• Stay calm. • Look at your watch or a c

lock and time the convulsion.

• Do not try to restrain yo ur child

and do not put anything intheirmouth.

• Stay with your child and lay them on their side.

• Loosen tight clothing fro m around

the neck and move object s away

that may cause injury. • Arrange to see your local

doctor/general practitione r after

the convulsion has stopped.

What is febrile convulsion?

Recurrence risk/Prognosis

What should I do whe n my child

develops fever in thefuture?

Siriraj hospital : Clinical practice guildline

Patient with fever and seizure (age 6 month – 5 years)1.History

taking

2.Physical examination

Assess cause of fever

•Tepid sponge

•Antipyretics

•Treat infection

Assess risk factor

• Age

• Neurological PE

• Type of seizure

•Age<12 month or 12-18 month with evidence of CNS infection

•Abnormal neurologicl exm

•Complex febrile convulsion

Consider LP CT scan or EEG

Normal investigation

Abnormal investigation

•Age > 18 months

•Normal neurologicl exm

Simple febrile convulsion

Treat accordingly

If first seizure >>Reassure and follow up

If recurrence >> Discuss about oral diazepam prophylaxis

Progression

First day, she had not repeated convulsions but still high grade fever and minimal watery stool.

By physical examination, she had signs of mild dehydration so intravenous antibiotics should be continued and we corrected her dehydration by IVF replacement as maintenance fluid + 3% deficit .

Progression

After that, she still had high grade fever until the 4th day of admission then her fever was resolved and clinical symptom was improved.

Moreover, she was able to eat a little so we still gave IV antibiotics until the 7th day of admission.

Hemoculture 20/12/50 : no growth

Progression DATE 20/12/50 21/12/50 22/12/50 23/12/50 24/12/50 25/12/50 26/12/50

Ceftriaxone Day 1 Day 7Day 2 Day 3 Day 4 Day 5 Day 6

37

38.6

40.4

39.3

39.8

36.0

37.3 37.0

38.2

38

41

40

39

35

36

Progression

While she was admitting , her mother complained that she had snoring. As a result, we investigated about “Obstructive sleep apnea” and we monitored overnight pulse oximetry.

The result is normal study.

Progression

Her status before discharge ; She had vital signs stable,

no fever, no diarrhea, no signs of dehydration, no convulsion and home medications. Therefore, she didn’t had any medications to prophylaxis for febrile seizure.

She had follow up at neurology clinic for 1 week.

THANK YOU &

Happy new year !!!!

Extern conference January 3 rd 2008. Case A Thai 2 years 10 months old girl Chief Complaint...

Documents

Transcript of Extern conference January 3 rd 2008. Case A Thai 2 years 10 months old girl Chief Complaint...