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Case Summary: Parinith Gowda

Patient Demographics

• Name: Parinith Gowda
• UHID: MH0110687 / 1106878
• Age/Sex: ~5 years, Male (pediatric patient)
• Department: Paediatrics
• Hospital: Ramaiah Memorial Hospital (Mount Sinai affiliate), Bengaluru
• Treating Doctor: Dr. RK Namara (Paediatrics)

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Case Reconstruction from Documents

Provisional Diagnosis

Chief Complaint / History of Present Illness (Page 5, partial OCR)

• The child presented with seizure-like episodes - "not able to bend / not able to speak / unable to see" - suggesting focal neurological deficits
• Episodes are of unilateral (left-sided) motor involvement
• Family noticed the child was unable to perform normal activities
• Duration: Approximately since ~16 months or earlier based on notes
• Presented to emergency/OPD with acute exacerbation

Allergies

• No known drug allergies (NKDA)
• No food allergy, no blood transfusion reaction history

Birth / Neonatal History (Page 6)

• Birth Weight: 2.6-2.8 kg (slightly low-normal)
• Type of Delivery: NVD (Normal Vaginal Delivery)
• Term: Term baby
• NICU Admission: Yes (documented)
• Birth Asphyxia: Mentioned/queried - this is clinically significant as perinatal hypoxic-ischemic injury can cause hemiplegia
• Neonatal screening (TSH, Hearing, G6PD, Thalassemia) - status recorded

Developmental History (Page 6)

• Immunization: Complete
• Gross Motor, Fine Motor, Language, Social: Noted as Normal with some developmental lag elements

Vital Signs (Page 7)

• Pulse: ~140 bpm (tachycardia for age)
• BP: 100/70 - 120/80 mmHg (normal range for pediatric)
• SpO2: 99%
• Temperature: Elevated (~febrile)
• Weight: ~15 kg
• MUAC (Mid Upper Arm Circumference): 14.5 cm

General/Systemic Examination (Pages 7-8)

• No icterus, no clubbing, no cyanosis, no lymphadenopathy
• Neurological: Left-sided weakness/hemiplegia noted
• Anxious: Yes
• Depressed: Yes (behavioral/psychological screening positive)
• Nutritional status: Thin

Investigations Ordered (Page 8)

• CBC (Complete Blood Count)
• CRP (C-Reactive Protein)
• Hematology panel

Lab Values from Progress Notes (Page 12 - most detailed)

Medications Prescribed

• Fentanyl 5 mcg IV - narcotic analgesic/sedation (noted in the narcotic drug chart - suggesting the child needed procedural sedation or pain management)

• Levetiracetam (LEV) 200mg IV - Anti-Epileptic Drug (AED), given as infusion, duration noted as ~034 SAC (possibly 30 minutes infusion), documented as "ENG-LEVETIRACETAM 200MG + IV"
• Other AEDs continued - notes say "to be continued"

• IV Labetalol - for blood pressure management
• IV Fluids continued
• Antiepileptics (Fentanyl sedation for EEG/procedure or seizure control)
• Benzodiazepine (possibly midazolam - referenced in sedation chart)

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Detailed Clinical Analysis

Diagnosis: Left Hemiplegia with Epilepsy

1. Perinatal causes (most likely here given NICU admission): Hypoxic-ischemic encephalopathy (HIE), periventricular leukomalacia (PVL), neonatal stroke
2. Structural brain anomaly
3. Cerebral palsy (hemiplegic type) - very commonly associated with seizures in 30-50% of cases
4. Rasmussen's encephalitis - progressive epilepsy with hemiplegia
5. Sturge-Weber syndrome - port-wine stain, hemiplegia, epilepsy
6. Post-infectious/autoimmune encephalitis

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Questions Doctors Ask During Case Presentation

History-Based Questions

1. "What is the exact nature of the seizures?" - Focal vs. generalized? Duration? Any postictal phase (Todd's palsy)? Frequency per day/week?
2. "When was the onset of left-sided weakness - was it from birth or acquired?" - Distinguishes congenital hemiplegia (CP) vs. acquired stroke
3. "Was there birth asphyxia? Any NICU stay and for how long?" - Key etiological clue
4. "What was the birth weight and gestational age?" - Prematurity is a major risk for periventricular leukomalacia causing hemiplegia
5. "Any fever or illness preceding the seizure?" - Febrile seizures, encephalitis
6. "Any regression in milestones?" - Suggests Rasmussen's or metabolic disorder
7. "What AEDs has the child been on previously? Any failures?" - Medication history
8. "Is there a family history of epilepsy or neurological disorders?"
9. "Any port-wine stain, skin lesions, or dysmorphic features?" - Neurocutaneous syndromes (Sturge-Weber, TSC)
10. "Any head trauma?"

Examination/Clinical Questions

1. "What are the upper and lower limb tone findings on the left side?" - Spasticity, hyperreflexia, Babinski sign
2. "What is the speech status?" - Broca's area involvement (right-handed child with right-sided brain lesion)
3. "What does the EEG show?" - Focal or generalized epileptiform discharges
4. "What does the MRI brain show?" - Cortical atrophy, porencephaly, gliosis, stroke, abnormal myelination
5. "Is the seizure controlled currently?" - Breakthrough seizures on current AED

Pharmacist-Specific Questions During Presentation

1. "What is the dose of levetiracetam on a mg/kg basis?" - The standard pediatric dose is 20-60 mg/kg/day in 2 divided doses. For a 15 kg child, 200 mg IV may be a loading or starting dose - pharmacist will verify this is appropriate.
2. "What is the indication for IV vs oral levetiracetam?" - Is the child NPO? Can we convert to oral formulation to reduce cost and ease discharge planning?
3. "What is the route and rate of fentanyl infusion?" - Dose safety check (fentanyl 5 mcg/kg IV is standard for procedural sedation, but needs weight-based verification for a pediatric patient). Risk of respiratory depression.
4. "Was levetiracetam loading given?" - Standard emergency loading is 20-60 mg/kg IV over 15 min. Clarify whether this was a loading dose or maintenance.
5. "Are there any drug-drug interactions?" - Levetiracetam has few interactions, but check for CNS depressant combinations with fentanyl/sedatives.
6. "What is the target AED serum level?" - Levetiracetam therapeutic range is 12-46 mcg/mL; was a level drawn?
7. "What is the renal function?" - Levetiracetam is renally cleared (60% unchanged in urine). Dose adjustment needed if eGFR is reduced. Urinalysis showed pus cells - any renal compromise?
8. "Why was labetalol given? Is the child hypertensive?" - Seizures can cause transient hypertension; need to distinguish from primary hypertensive encephalopathy.
9. "What is the duration of IV therapy planned before step-down to oral?"
10. "Was sodium valproate or another first-line AED considered before levetiracetam?" - In focal epilepsy with hemiplegia, both are used, but valproate has hepatotoxicity concerns (note the elevated AST/ALP in labs).
11. "Are the liver enzymes (AST/ALP elevated) a concern for valproate use?" - Pharmacist would flag this as a contraindication to valproate if enzymes are significantly elevated.
12. "What is the pain scale score and is fentanyl appropriate for this child's age and weight?" - FLACC scale or Wong-Baker faces used here.
13. "Is the child on any home medications that were not reconciled?" - The medication reconciliation form on Page 7 should be cross-checked.
14. "What is the nutritional status and is enteral feeding adequate?" - NPO status noted; nutrition pharmacist question about caloric needs.
15. "What are the plans for monitoring AED toxicity?" - CBC (levetiracetam can cause thrombocytopenia), LFTs, behavioral side effects (irritability, aggression - common with levetiracetam in children).

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Summary for Presentation

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1. Etiology workup - Why does this child have hemiplegia? (MRI findings, birth history)
2. Seizure classification and AED choice - Why levetiracetam? What are alternatives? Dose optimization.
3. Pharmacist role - Weight-based dosing verification, IV-to-oral conversion, monitoring for AED toxicity, interaction screening, liver enzyme significance for drug selection.

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Standard Emergency Treatment: Pediatric Stroke & Seizure

With Infusion Rate / Dilution Calculations (based on patient weight: ~15 kg)

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PART 1 - PEDIATRIC SEIZURE / STATUS EPILEPTICUS

Definitions

• Seizure: Abnormal, excessive, or synchronous neuronal activity. Treat actively if >5 minutes.
• Status Epilepticus (SE): Continuous seizure lasting >20 minutes, OR two or more seizures without recovery of consciousness between them.
• Refractory SE: Seizures not responding to first- and second-line AEDs.

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STEP-BY-STEP EMERGENCY PROTOCOL

Immediate (0-5 minutes) - ABCs First

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STEP 1 - First-Line: Benzodiazepines (0-5 minutes)

A. Lorazepam (Ativan) - PREFERRED if IV access

• Dose: 0.1 mg/kg IV (max single dose: 4 mg)
• Rate: Slow IV push over 1-2 minutes
• May repeat once after 5 minutes if seizure continues
• Max total dose: 0.2 mg/kg (8 mg)

Dose = 0.1 mg/kg × 15 kg = 1.5 mg
Lorazepam available: 2 mg/mL (undiluted)
Volume to draw = 1.5 mg ÷ 2 mg/mL = 0.75 mL
Dilute 0.75 mL in 2-3 mL NS → give slowly over 1-2 min

B. Midazolam (Versed) - If no IV access (IM or intranasal)

• IM dose: 0.2 mg/kg IM (max 10 mg)
• Intranasal dose: 0.2 mg/kg divided between both nares

0.2 mg/kg × 15 kg = 3 mg IM
Midazolam available: 5 mg/mL
Volume = 3 mg ÷ 5 mg/mL = 0.6 mL IM

C. Diazepam (Valium) - Rectal route (no IV/IM access)

• Rectal dose: 0.5 mg/kg PR (max 10 mg)
• Calculation for 15 kg: 0.5 × 15 = 7.5 mg PR

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STEP 2 - Second-Line AEDs (5-30 minutes, if seizure continues)

Option 1: Levetiracetam (DRUG IN THIS CASE)

• Dose: 20-60 mg/kg IV (loading dose)
• Standard loading: 20-30 mg/kg IV for acute seizure; up to 60 mg/kg in refractory SE
• Rate: Infuse over 15 minutes
• Max dose: 4500 mg

Loading dose = 20 mg/kg × 15 kg = 300 mg
(Patient received 200 mg - likely starting/maintenance dose)

Levetiracetam available: 500 mg/5 mL (100 mg/mL) concentrate
Draw: 300 mg ÷ 100 mg/mL = 3 mL

Standard dilution: Add 3 mL (300 mg) to 50 mL NS
Final concentration: 300 mg/50 mL = 6 mg/mL

Infusion rate: 50 mL over 15 min = 200 mL/hr (set on pump)

Maintenance dose (after loading): 10-20 mg/kg/day divided every 12 hours For 15 kg: 10 mg/kg × 15 = 150 mg every 12 hours IV/PO

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Option 2: Fosphenytoin (preferred over phenytoin IV in children)

• Dose: 20 mg/kg IV as phenytoin equivalents (PE)
• Max rate: 3 mg PE/kg/min (not to exceed 150 mg PE/min)
• Monitor: BP and ECG during infusion

Dose = 20 mg PE/kg × 15 kg = 300 mg PE
Fosphenytoin available: 75 mg PE/mL
Volume = 300 mg PE ÷ 75 mg PE/mL = 4 mL

Dilute 4 mL in 50 mL NS
Max rate = 3 mg PE/kg/min × 15 kg = 45 mg PE/min
Concentration = 300 mg PE/50 mL = 6 mg PE/mL
Rate = 45 mg PE/min ÷ 6 mg PE/mL = 7.5 mL/min = 450 mL/hr
(Run over ~7 minutes minimum)

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Option 3: Valproic Acid (Sodium Valproate) IV

• Dose: 20-40 mg/kg IV
• Rate: Infuse over 5-10 minutes (can go up to 60 mg/kg in refractory SE)
• Avoid if: Liver disease (note elevated AST/ALP in this patient - use with CAUTION or AVOID)

Dose = 20 mg/kg × 15 kg = 300 mg
Valproate available: 100 mg/mL (5 mL = 500 mg vial)
Volume = 300 mg ÷ 100 mg/mL = 3 mL

Dilute 3 mL in 50 mL NS
Rate: 50 mL over 10 min = 300 mL/hr

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Option 4: Phenobarbital

• Dose: 10-20 mg/kg IV (loading); max single dose 1000 mg
• Rate: 1 mg/kg/min, max 100 mg/min
• Risk: Significant respiratory depression, especially combined with benzodiazepines

Dose = 15 mg/kg × 15 kg = 225 mg
Phenobarbital available: 200 mg/2 mL (100 mg/mL)
Volume = 225 mg ÷ 100 mg/mL = 2.25 mL

Dilute to 50 mL in NS
Rate = 1 mg/kg/min × 15 kg = 15 mg/min
Concentration = 225 mg/50 mL = 4.5 mg/mL
Rate = 15 mg/min ÷ 4.5 mg/mL = 3.33 mL/min = 200 mL/hr

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STEP 3 - Refractory SE (seizure >30-60 min, no response to steps 1 & 2)

Midazolam continuous infusion (first choice in refractory SE)

• Loading bolus: 0.1-0.2 mg/kg IV
• Maintenance infusion: 0.05-0.4 mg/kg/hr (titrate to seizure suppression)

Loading: 0.2 mg/kg × 15 kg = 3 mg bolus
Midazolam: 5 mg/mL; volume = 0.6 mL bolus

INFUSION PREPARATION:
Take 15 mg midazolam (3 mL of 5 mg/mL) → dilute in 47 mL NS
Final: 15 mg/50 mL = 0.3 mg/mL

Starting rate = 0.1 mg/kg/hr × 15 kg = 1.5 mg/hr
Rate = 1.5 mg/hr ÷ 0.3 mg/mL = 5 mL/hr

Titrate up to: 0.4 mg/kg/hr = 6 mg/hr = 20 mL/hr (max initial)

Propofol infusion (>12 years or as directed - use cautiously in children)

• Loading: 1-2 mg/kg IV
• Infusion: 2-5 mg/kg/hr
• ⚠️ Propofol Infusion Syndrome risk if >48 hours or high doses in children

Pentobarbital (last resort, barbiturate coma)

• Loading: 5 mg/kg IV at 50 mg/min
• Maintenance: 1-3 mg/kg/hr infusion

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PART 2 - PEDIATRIC STROKE: EMERGENCY MANAGEMENT

Two Types Managed Differently

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IMMEDIATE (First 60 minutes - "Brain Attack Protocol")

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ANTITHROMBOTIC THERAPY (Pediatric Ischemic Stroke)

Aspirin (for arterial ischemic stroke without cardiac source)

• Dose: 3-5 mg/kg/day PO (max 81-325 mg/day)
• Given within 24-48 hrs of onset (after hemorrhage excluded)
• Duration: At least 3-5 years or until etiology is fully evaluated

Aspirin 3 mg/kg/day × 15 kg = 45 mg/day
Use: Junior aspirin 75 mg tablet (give half = 37.5 mg) or
dispersible aspirin 81 mg tab once daily

Low Molecular Weight Heparin (LMWH) - for cardioembolic or dissection strokes

• Therapeutic dose (treatment): 1 mg/kg SC every 12 hours (age <2 months: 1.5 mg/kg q12h)
• Prophylactic dose: 0.5 mg/kg SC every 12 hours
• Monitor: Anti-Xa levels (target 0.5-1.0 IU/mL for treatment; 4 hours post-dose)

Dose = 1 mg/kg × 15 kg = 15 mg SC q12h
Enoxaparin available: 20 mg/0.2 mL, 40 mg/0.4 mL pre-filled syringes
Volume = 15 mg × (0.2 mL/20 mg) = 0.15 mL SC q12h

Unfractionated Heparin (UFH) - used in first 24-48 hrs of cardioembolic stroke

• Loading: 75 units/kg IV over 10 min
• Maintenance: 18-20 units/kg/hr
• Target aPTT: 60-85 seconds

Loading: 75 units/kg × 15 kg = 1125 units IV over 10 min
Heparin 5000 units/mL:
Volume = 1125 units ÷ 5000 units/mL = 0.225 mL
Dilute in 10 mL NS → give over 10 min

MAINTENANCE INFUSION:
Rate = 20 units/kg/hr × 15 kg = 300 units/hr
Standard drip: Heparin 25,000 units in 250 mL NS = 100 units/mL
Rate = 300 units/hr ÷ 100 units/mL = 3 mL/hr
Adjust per aPTT every 6 hours using pediatric heparin nomogram

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IV tPA (Alteplase) - CONTROVERSIAL in Pediatric Stroke

• Adult dose: 0.9 mg/kg IV (max 90 mg); 10% as bolus, rest over 60 min
• Pediatric use: Currently NOT routinely recommended (insufficient evidence; FDA approval is for adults only)
• The 2019 AHA/ASA pediatric stroke guidelines state it "may be considered" in selected cases (age >2 years, within 4.5 hrs, no hemorrhage, significant deficit) on a case-by-case basis
• Recent 2025 review (PMID: 40906584 - Radiographics) confirms the evidence base remains limited and tPA use in children should involve a pediatric stroke specialist

Dose = 0.9 mg/kg × 15 kg = 13.5 mg (max 90 mg)
Bolus = 10% = 1.35 mg IV over 1 min
Remaining = 12.15 mg over 60 min

Alteplase 1 mg/mL (reconstituted):
Bolus volume: 1.35 mL IV push
Infusion: 12.15 mL in 50 mL NS → run at 50 mL/hr over 60 min

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BP MANAGEMENT IN PEDIATRIC STROKE

• Dose: 0.2-1 mg/kg IV bolus (max 40 mg per dose)
• Infusion: 0.4-3 mg/kg/hr

Bolus: 0.5 mg/kg × 15 kg = 7.5 mg IV over 2-5 min
Labetalol available: 5 mg/mL (20 mL vial)
Volume = 7.5 mg ÷ 5 mg/mL = 1.5 mL IV push

INFUSION (if needed):
1 mg/kg/hr × 15 kg = 15 mg/hr
Dilute 60 mg (12 mL) in 48 mL NS → 60 mg/60 mL = 1 mg/mL
Rate = 15 mg/hr ÷ 1 mg/mL = 15 mL/hr

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NEUROPROTECTION IN PEDIATRIC STROKE

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QUICK REFERENCE SUMMARY TABLE (for 15 kg pediatric patient)

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