This resident is referring a 4-year-old female patient with a history of epilepsy, cerebral palsy, and developmental delays who is experiencing breakthrough seizures. The patient was recently admitted for status epilepticus and is now experiencing increasing seizure frequency despite treatment. The resident's assessment is refractory status epilepticus likely due to decreased seizure threshold from ear infection. The plan is to intubate the patient, start an anti-seizure drip, and transfer to the PICU for further management and monitoring.
This resident is referring a 4-year-old female patient with a history of epilepsy, cerebral palsy, and developmental delays who is experiencing breakthrough seizures. The patient was recently admitted for status epilepticus and is now experiencing increasing seizure frequency despite treatment. The resident's assessment is refractory status epilepticus likely due to decreased seizure threshold from ear infection. The plan is to intubate the patient, start an anti-seizure drip, and transfer to the PICU for further management and monitoring.
This resident is referring a 4-year-old female patient with a history of epilepsy, cerebral palsy, and developmental delays who is experiencing breakthrough seizures. The patient was recently admitted for status epilepticus and is now experiencing increasing seizure frequency despite treatment. The resident's assessment is refractory status epilepticus likely due to decreased seizure threshold from ear infection. The plan is to intubate the patient, start an anti-seizure drip, and transfer to the PICU for further management and monitoring.
This resident is referring a 4-year-old female patient with a history of epilepsy, cerebral palsy, and developmental delays who is experiencing breakthrough seizures. The patient was recently admitted for status epilepticus and is now experiencing increasing seizure frequency despite treatment. The resident's assessment is refractory status epilepticus likely due to decreased seizure threshold from ear infection. The plan is to intubate the patient, start an anti-seizure drip, and transfer to the PICU for further management and monitoring.
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GOOD EVENING DOCTOR, THIS IS JAYMEE QUINDARA, 1 ST YEAR RESIDENT UNDER THE MISC WARD
RESPECTFULLY REFERRING PATIENT BAYUDANG, DANICA JANE, 4YO FEMALE, IS A KNOWN CASE OF EPILEPSY, CP SPASTIC DIPLEGIC GDD SINCE 202O , HYDROCEPHALUS SECONDARY TO BACETRIAL MENINGITIS S/P VP SHUNTING (2021) S/P PEG INSERTION AND WAS ADMITTED LAST APRIL 2022 FOR STATUS EPILEPTICUS MAINTAINED ON: 1. LEVITERACETAM 100MG/ML 10 ML AT 35MG/KG/DAY 2. PHENYTOIN 50MG/PPTAB 1 PPTAB BID AT 5MG/KG/DAY 3. BACLOFEN 10MG 1 TAB BID (1MG/KG/DAY) 4. PROPANOLOL 10MG/TAB 1 TAB 2X A DAY (1MG/KG/DAY REGULAR FOLLOW-UP
THE CONDITION OF THE PATIENT STARTED 13 HOURS PTC, PATIENT HAD SEIZURE CHARACTERIZED AS GENERALIZED TONIC CLONIC LASTING FOR 3-5MINUTES. LEVITERACETAM WAS GIVEN AT 35MG/KG/DAY. NO ASSOCIATED FEVER, COUGH COLDS, ABDOMINAL PAIN NOR VOMITING.
HOWEVER AT 2 HOURS PTC, PATIENT HAD ANOTHER SEIZURE WITH THE SAME SEMIOLOGY LASTING FOR 8-10 MINS. LEVETIRACETAM WAS GIVEN IMMEDIATELY.
FEW MINUTES PTC, PATIENT HAD ANOTHER SEIZURE STILL SAME SEMIOLOGY FOR 5 MINUTES HENCE WAS RUSHED TO OUR INSTITUTION AND WAS SUBSEQUENTLY ADMITTED.
ROS: (+) WEIGHT GAIN, (-) FEVER, (-) COUGH, (-) COLDS, (-) NASO-AURAL DISCHARGE, (-)DIFFICULTY OF BREATHING/ SHORTNESS OF BREATH, (-) CHANGES IN BOWEL, (+) NOTED FOUL ODOR OF URINE
PMH: PATIENT IS A KNOWN CASE OF EPILEPSY, CP SPASTIC DIPLEGIC GDD SINCE 202O AND WAS ADMITTED LAST APRIL 2022 FOR STATUS EPILEPTICUS MAINTAINED ON LEVITERACETAM 100MG/ML AT 35MG/KG/DAY, PHENYTOIN 50MG/PPTAB BID AT 5MG/KG/DAY, BACLOFEN 10MG 1 TAB BID (1MG/KG/DAY) AND PROPANOLOL 10MG/TAB 1 TAB 2X A DAY (1MG/KG/DAY , (-) ASTHMA, (-) ALLERGIES TO FOOD/MEDICATION
SOCIAL AND ENVIRONMENTAL HX: NO OTHER FAMILY MEMBERS WITH EPILEPSY OR SEIZURE, COUGH, COLDS AND FEVER. NO SMOKER ON OTHE HOUSEHOLD, USES MINERAL WATER FOR DAILY USE
AT THE EMERGENCY ROOM, THE FOLLOWING WERE THE FINDINGS
OBJECTIVE AWAKE ARM BORN IRRITABLE NOT IN RESPIRATORY DISTRESS BP 90/60 CR 74 RR 22 T 36.8 SP02 96 W: 23 SKIN: WARM NO TOUCH, NO RASHES NOTED HEENT: ANICTERIC SCLERA, PINK PALPEBRAL CONJUNCTIVA, NO TPC, NO CLADS, WITH ERYTHEMA ON EXTERNAL CANAL OF LEFT EAR, NORMAL FINDINGS OF RIGHT EAR CHEST AND LUNGS: SCE, NO RETRACTION CBS AP, PMI AT 5TH ICS LMCL, NRRR, NO MURMUR ABD: FLABBY, WITH INTACT PEG, NON ERYTHEMATOUS BASE, NO DISCHARGES LOCATED ON THE EPIGASTRIC AREA, NONDISTENDED ABDOMEN, NONTENDER NORMOACTIVE BOWEL SOUND FEP, CRT LESS THAN 2 SECONDS NEURO CEREBRAL: AWAKE CN I-NOT ASSESSED II ,III, IV, VI-PUPILS 2-3MM ERTL, INTACT EOMS,NO NYSTAGMUS V- VII- NO FACIAL ASSYMETRY VIII- IX, X- WITH GAG REFLEX XI-ABLE TO SHRUG SHOULDERS XII-TONGUE IN MIDLINE
ASSESSMENT AT THE ER:
>BREAKTHROUGH SEIZURE IN STATUS EPILEPTICUS PROBABLY SECONDARY TO DECREASED THRESHOLD FOR INFECTION (T/C OTITIS EXTERNA, T/C UTI), EPILEPSY, GENERALIZED, STRUCTURAL, CEREBRAL PALSY, SPASTIC DIPLEGIC, GLOBAL DEVELOPMENTAL DELAY
DIAGNOSTICS: CBG-112 THE RESULTS OF THE CBC ARE AS FOLLOWS: NORMAL HGB: 142 HCT: 0.40 WBC: 5.38 NT: 53 LM: 38 MN: 6 EO: 3 RBC: 4.61 PLT: 267
CXR: BOTH LUNGS HYPOAREATED, WITH EMERGENCE OF HAZY AND RETICULAR OPACITIES ON BOTH LUNGS LIKELY PNEUMONIC PROCESS. HEART NORMAL IN SIZE
AT THE ER THE FOLLOWING THERAPEUTICS STARTED
>START D5LRS 1L X65CC/HR (m%) >MAINTAIN ON O2 SUPPORT: FACE MASK AT 5LMP >START LOADING DOSE OF LEVETIRACETAM 400MG IV + 100CC PNSS AS INFUSION FOR 15 MINUTES, THEN MAINTAIN ON 200MG +50CC PNSS AS INFUSION FOR 15 MIN, 8 HOURS FROM LOADING DOSE
DIAZEPAM 6MG IV FOR FRANK SEIZURE (0.3MG/KG/DOSE) SIDE LYING POSITION O2 AT BEDSIDE
AT OUR WARDS:
WHEN THE PATIENT WAS TRANSFERRED TO THE WARD PATIENT WAS NOTED TO HAVE ANOTEHR SEIZURE EPISODE OF THE SAME SEMIOLOGY LASTING FOR 3-5 MINUTES HENCE WAS GIVEN DIAZEPAM 6MG IV LOADED GIVEN ANOTHER LOADING DOSE OF LEVETERACETAM AT 400MG IV + 100CC PNSS AS INFUSION FOR 15 MINUTES.
AT 6AM WE OBSERVED THE PATIENT HAD ANOTHER EPISODE OF SEIZURE OF SAME SEIZURE SEMIOLOGY NOW AT 5MINUTES HENCE GIVEN PHENYTOIN 400MG IV + 100CC PNSS VIA INFUSION FOR 30 MINS (20MG/KG, LOADING DOSE) THEN WE OBSERVED NO RECURRENCE OF SEIZURE HENCE WE GIVE MAINTENANCE PHENYTOIN 90MG IV Q12 (8MKDAY) 6 HOURS AFTER LOADING DOSE AT THE FOLLOWING TIME 12AM AND 12PM AND LEVETIRACETAM 450MG IV Q12 TO BE GIVEN AT 6AM AND 6PM
AT 3 PM PATIENT HAD ANOTHER EPISODE OF SEIZURE FOR 15 MINUTES GAVE THE MAINTENANCE DOSE OF PHENYTOIN AND ANOTHER DIAZEPAM HOWEVER WAS NOTED TO HAVE INCREASING FREQUENCY OF SEIZURE WITH DECREASE IN INTERVAL OF 1MINUTE WITH NO NOTED REGAIN IN CONSICOUSSNESS
HENCE WE ASSESSED CURRENTLY THE PATIENT AS:
REFRACTORY STATUS EPILEPTICUS, BREAKTHROUGH SEIZURE IN STATUS EPILEPTICUS PROBABLY SECONDARY TO DECREASED THRESHOLD FOR INFECTION (T/C OTITIS EXTERNA LEFT), EPILEPSY, GENERALIZED, STRUCTURAL, CEREBRAL PALSY, SPASTIC DIPLEGIC, GLOBAL DEVELOPMENTAL DELAY POST ICTAL STATE, NOT IN CPD AS, PPC, PINK MOIST LIPS AND ORAL MUCOSA, EAR NO DISHCARGE, INTACT TM BILATERALLY, SCWE,VESICULAR BREATH SOUNDS AP, PMI AT 4TH ICS LMCL NO MURMUR FLABBY ABDOMEN, SOFT, NAB INTACT PEG SITE. WARM EXTREMITIES, CRT <2S FEP
HC: 49cm
AWAKENS TO PAIN BUT IMMEDIATELY FALLS TO SLEEP
CN: 2- EQUALLY REACTIVE TO LIGHT ISOCORIC 3-4 CM BILATERALLY 3,4,6: FULL EOMS 5 - + CORNEAL REFLEX 7: NO FACIAL ASSYMETRY 8: RESPONSIVE TO VOICE 9,10: +GAG 11: GOOD TONE OF SCM 12: MIDLINE
MOTOR: NOTED SPASTICITY ON ALL EXTREMITIES, NO ATROPHY
SENSORY: RESPONSOBE
AS OUR ASSESSMENT OF REFRACTORY SEIZURE, OUR PLAN ARE AS FOLLOWS
PLAN:
WE SECURED THE AIRWAY AND INTUBATED AND HOOKED THE PATIENT TO MECHANICAL VENTILATION AT SIMV WITH THE FOLLOWING SETTINGS: FIO2: 60 RR: 20 PIP: 20 PEEP: 4
IVF: D5LRS 500CC AT 65CC/HOUR (MAINTENANCE)
DIET: NPO
DIAGNOSTICS: >CT SCAN PLAIN AND CONTRAST >BUN AND CREA >SHUNT SERIES THERAPEUTICS: >STARTED MIDAZOLAM DRIP AS FOLLOWS AT 1MG/KG/MIN - MIDAZOLAM DRIP: 5ML -D5W: 20 ML TO MAKE 25 ML TO RUN AT 2.3CC/HOUR ( 1MCG/KG/MIN) TO TITRATE BY 2CC Q15MIN MAXIMUM OF 41CC/HOUR (18MCG/KG/MIN) UNTIL PATIENT IS SEIZURE FREE
CONTINUE OTHER MEDICATIONS TO BE GIVEN VIA PEG
> LEVETIRACETAM 100MG/ML AT 5ML Q12 (500MG/DAY) >PHENYTOIN 100MG/CAP 1CAPSULE Q8 (300MG/DAY) >BACLOFEN 10MG 1 TAB BID (1MG/KG/DAY) >PROPANOLOL 10MG/TAB 1 TAB 2X A DAY (1MG/KG/DAY)
PLACE ON SEIZURE PRECAUTION
DIAZEPAM 6MG IV FOR FRANK SEIZURE (0.3MG/KG/DOSE) MAX DOSE OF 10MG/24 HOURS
>TRANSFER THE PATIENT TO PICU
>DR. TRAJANO (PEDIA-NEURO SERVICE) UPDATED AND COGNIZANT >DR. ANDRES (MISC CONSULTANT) UPDATED AND COGNIZANT WE WILL MONITOR THE PATIENT’S VS Q1 INCLUDING BP WE WILL MONITOR THE PATIENT’S I&O
