Seizure (peds)

Background

• Consider neuroimaging for new-onset focal seizure
• Todd paralysis
  • Temporary focal deficit up to 36 hr post-seizure
• Lateral tongue biting - 100% sp

Status Epilepticus

• Seizure or recurrent sz lasting >5min w/o regaining consciousness
  • If prolonged postictal state or longer than usual consider nonconvulsive status
    • Obtain emergency EEG; if not available trial of anticonvulsants appropriate
• Management
  • Glucose, chemistry, CBC, LFT, ?CSF, ?neuroimaging
  • Intubate if e/o apnea and persistent hypoxia
  • If use paralytic EEG monitoring should be arranged

Diagnosis

Seizure with a Fever

• CNS infection
• Lowered sz threshold in pts with epilepsy
• Febrile seizure

First-Time Afebrile Seizure

• If pt returns to baseline no labs/imaging necessarily indicated
  • Consider glucose, chemistry, utox
• LP only necessary if concern for meningitis
• EEG should be performed within 24-48hr
• Neuroimaging
  • Preferred test is outpt MRI
  • Consider emergent imaging for focal deficit, no return to baseline
• 40% have 2nd sz

Neonatal Seizures

• Often subtle, focal, poor prognosis
  • Less often have generalized tonic-clonic seizures
    • Findings include lip smacking, eye deviation, staring, ALTE
• Work-up
  • CBC, chemistry, UA, CSF (including HSV), utox (withdrawal)
  • Consider neuroimaging if concern for abuse, ICH, mass
  • Consider lactate, ammonia if concern for errors of metabolism
• Treatment
  • Start IV abx (including acyclovir)

Epileptic Seizures

• Epilepsy = 2 or more sz w/o acute provocation (fever, trauma)
• Often due to pt "outgrowing" their dosage
• Check levels of:
  • Phenytoin, carbamazepine, valproic acid
    • If low consider non-compliance, "outgrowing," vomiting, med interaction
• Pts with epilepsy may have lower sz threshold with febrile illness
  • Usually can limit ED w/u to fever evaluation

Seizure with VP Shunt

• Consider underlying epilepsy, shunt malfunction, CNS infection
  • If pt has fever seizure more likely 2/2 infection than malfunction
    • Consult pediatric neurosurgeon to tap the shunt
• Imaging
  • Obtain shunt series and head CT or MRI to evaluate for incr ventricular size

Seizure with Trauma

• "Impact seizures" (sz that occurs w/in minutes of head trauma)
  • Not associated with severe head injuries
• Sz that occur after this time more likely to represent intracranial injury

See Also

Febrile Seizure

Source

Tintinali

DDX

Events Masquerading as Seizures

Syncope

Breath-holding spells

Cataplexy

Narcolepsy

Vasovagal event

Standing for long periods of time

Standing quickly from laying or sitting

Hair-grooming syncope

Earring-changing syncope

Micturition syncope

Emotional distress or pain

Hypoglycemia

Hypovolemia

Sandifer syndrome (gastroesophageal reflux)

Acute life-threatening event

Acute dystonic reactions/drug reactions [i.e., promethazine (Phenergan)]

Movement disorders

Tics

Myoclonic jerks

Chills or rigors

Shudder attacks

Mannerisms

Self-stimulation

Choreoathetosis

Night terrors, sleep walking

Migraine variants

Benign paroxysmal vertigo

Nonepileptic paroxysmal event (pseudoseizure)

Treatment

1st Line

Drug	Route	Dose*	Maximum	Onset of Action	Duration of Action
Lorazepam	IV, IO, IN[[Image:]]	0.1 milligram/kg	4 milligrams	1–5 min	12–24 h
	IM	0.1 milligram/kg	4 milligrams	15–30 min	12–24 h
Diazepam	IV, IO	0.1–0.3 milligram/kg	10 milligrams	1–5 min	15–60 min
	PR	0.5 milligram/kg	20 milligrams	3–5 min	15–60 min
Midazolam	IV, IO	0.1–0.2 milligram/kg	4 milligrams	1–5 min	1–6 h
	IM	0.2 milligram/kg	10 milligrams	5–15 min	1–6 h
	IN	0.2 milligram/kg	10 milligrams	1–5 min	1–6 h
	Buccal[[Image:]]	0.5 milligram/kg	10 milligrams	3–5 min	1–6 h

2nd Line

• If sz persists for another 5 min after 2 doses of benzos switch to fosphenytoin or phenobarbital
  • Fosphenytoin is usually preferred 2nd line agent 
  • Consider phenobarb over fosphenytoin if febrile illness, <2yr

Drug	Route	Loading Dose	Repeat Dose	Maximum	IV Infusion
Fosphenytoin	IV, IM	15–20 milligrams/kg PE	5–10 milligrams/kg PE	30 milligrams/kg PE	3 milligrams/kg/min PE
Phenobarbital	IV	15–20 milligrams/kg	5–10 milligrams/kg	40 milligrams/kg	1–30 milligrams/min
Valproic acid	IV	20 milligrams/kg	15–20 milligrams/kg	40 milligrams/kg	5 milligrams/kg/h
Levetiracetam	IV	20–30 milligrams/kg	—	3 grams	—
Pentobarbital	IV	5–15 milligrams/kg	1–2 milligrams/kg	15 milligrams/kg	0.5–5.0 milligrams/kg/h
Propofol	IV	0.5–2.0 milligrams/kg	0.5–1.0 milligram/kg	5 milligrams/kg	1.5–4.0 milligrams/kg/h
Midazolam	IV	0.1–0.2 milligram/kg	0.1–0.2 milligram/kg	10 milligrams	0.05–0.4 milligram/kg/h

Third-Line Treatment

• Consider Valproic acid 25mg/kg over 1-5min; then infusion of 5mg/kg/hr

Hypoglycemia

 If hypoglycemia is present  <50 milligrams/dL, patients should be treated with a rapid infusion of 2 mL/kg of 25% dextrose in water.

Hyponatremia

• Hyponatremia can cause seizures, especially if sodium level is <120 mEq/L
• Goal of therapy is to correct the level to >120 mEq/L quickly to treat or prevent further seizure activity
  • Then correct  sodium to normal levels over the next 24 hours
  • If a patient is actively experiencing seizure, the treatment of choice is 3% NaCl.
  • An infusion of 20 mL/kg of 0.9% NaCl should be started immediately for patients in status epilepticus if delivery of 3% NaCl is delayed. The calculation for 3% NaCl is presented in Formula 129-1.

3% NaCl (513 mEq/1000 mL): Na deficit in total mEq = [(weight in kg) x (130 – serum Na level) x 0.6] over 20 minutes

OR

3% NaCl: 4 to 6 mL/kg over 20 minutes

If there is no seizure activity but the sodium level is below 120 mEq/L, 4 to 6 mL/kg of 3% NaCl or 20 mL/kg of normal saline can be given over an hour. The sodium level should be rechecked after the bolus to see if a second bolus is necessary

Hypocalcemia

• Hypocalcemia must be addressed by administration of calcium in order to treat seizures, because benzodiazepines are not effective in this setting
• Ten percent calcium gluconate (0.3 mL/kg administered slowly over 5 to 10 minutes) is the preferred type of IV calcium, because calcium chloride often causes local irritation.⁶