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PAEDIATRIC ALTERED
CONSCIOUS LEVEL GUIDELINE |
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DELPHI PROCESS
Round two
14. Prolonged convulsion
14 (vi) If the plasma sodium is less than 120 mmol/l and the convulsion is ongoing despite anticonvulsant treatment, an infusion of 5ml/kg of 3% saline should be given over one hour
|
Position |
Comment |
|
Neuro |
The sudden increase in sodium may aggravate matters. |
|
Paed |
Difficult. Depends how much less than 120, certainly if very low but may not be necessary if say 118, 119 ish. |
|
Metab |
I have generally relied on 0.9% saline to correct this slowly |
|
Neuro S |
I’m not confident about electrolytes in young kids but in adults would not use anything more than 1.8% saline |
|
Paed |
I would look it up and work something out |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
50% |
36% |
14% |
(vii) If the plasma sodium is less than 120 mmol/l and the convulsion is ongoing despite anticonvulsant treatment, an infusion of 5ml/kg of 3% saline should be given over 6 hours
|
Position |
Comment |
|
PICU |
SHOULD BE GIVEN FASTER IN THE PRESENCE OF ONOING SEIZURES |
|
Paed |
If between 115 and 120 consider this as probably helpful to correct sodium but other causes of fitting should also be sought |
|
Neuro S |
I’m not confident about electrolytes in young kids but in adults would not use anything more than 1.8% saline |
|
Endo |
Although rapidity of correction probably depends on cause eg rapid correction in CAH in infancy could be corrected more quickly |
|
PICU |
too slow |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
33% |
27% |
40% |
(viii) If the plasma sodium is less than 115 mmol/l and the convulsion is ongoing despite anticonvulsant treatment, an infusion of 5ml/kg of 3% saline should be given over one hour
|
Position |
Comment |
|
Renal |
Actually needs more - nearer 9 ml/kg. |
|
Paed |
Would feel more comfortable risking this fast rate if sodium really this low ( balancing risk of very prolonged convulsion vs risk of pontine myelinolysis). Would probably start at this rate ( but slow down if fitting stops promptly) |
|
Metab |
Don’t know. The only cases of Na this low I have dealt with were not convulsing, and the Na came up with under 24 hours of 0.9% NaCl, and a too-rapid rise was avoided |
|
PICU |
and infusion continued until normal range |
Agreed |
Neither agree nor disagree |
Disagreed |
|
86% |
7% |
7% |
(ix) If the plasma magnesium is less than 0.75 mmol/l and the convulsion is ongoing, an infusion of magnesium sulphate 50mg/kg should be given over one hour.
|
Position |
Comment |
|
Renal |
A level of 0.75 mmol/l is normal |
|
Paed |
Prefer lower limit of 0.65 as in (x) below. If only just below 0.75 unlikely to be sole cause of fitting and other causes should be sought |
|
Metab |
Too high a threshold. Too aggressive |
|
Paed |
I would look up the dose |
|
PICU |
and check Ca++ and correct too |
|
Agreed |
Neither agree nor disagree |
Disagreed |
|
33% |
34% |
33% |
(x) If the plasma magnesium is less than 0.65 mmol/l and the convulsion is ongoing, an infusion of magnesium sulphate 50mg/kg should be given over one hour.
|
Position |
Comment |
|
Renal |
Need to look at plasma calcium as well |
|
PICU |
MG USUALLY MUCH LOWER WITH SEIZURES – UNLESS POST RENAL TRANSPLANT, AND THE DEBATE IS WHETHER IT IS LOW CA OR LOW MG |
Agreed |
Neither agree nor disagree |
Disagreed |
|
80% |
13% |
7% |