Increasingly, children with intractable epilepsy are undergoing implantation of the Cyberonics vagus nerve stimulator (Neurocybernetic Prosthesis System). This devise is programmed to deliver a stimulus at a specific intensity and frequency for a specific interval (e.g., 15 s every 3 min). Although the mechanism of action is uncertain, electrical stimulus of the left vagus nerve can significantly reduce seizure frequency. Common side effects include hoarseness and difficulty swallowing during stimulation. Problems with instrumentation are unlikely to warrant an emergency department visit. A malfunctioning stimulator can be temporarily turned off by taping a magnet over the subcutaneous pacemaker.
The ketogenic diet has been used with increasing frequency in the management of childhood epilepsy. Ketones are an alternative energy source for cerebral metabolism. By severely restricting glucose and increasing fat intake, ketosis can be maintained and seizure control improved. There are several concerns about an emergency department visit that warrant mention. It is necessary to maintain ketosis and, as a result, glucose infusions should be avoided if possible, and prescriptions given should have no measurable carbohydrate content. This is most easily managed by consultation with the prescribing neurologist, associated dietician, and pharmacist. Hematuria and flank pain may be due to renal calculi. Pancreatitis is an uncommon occurrence in children on the ketogenic diet.
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