Seizure, Pediatric, Emergency Medicine

Basics

Description

Sudden, abnormal discharges of neurons resulting in a change in behavior or function

Etiology

Febrile seizures
Infection
Idiopathic
Trauma
Toxicologic:
- Ingestion
- Drug action
- Drug withdrawal
Metabolic:
- Hypoglycemia
- Hypocalcemia
- Hypo/hypernatremia
- Inborn errors of metabolism
Perinatal hypoxia
Intracranial hemorrhage
CNS structural anomaly or malformation
Degenerative disease
Psychogenic

Diagnosis

Signs and Symptoms

Neonates

Subtle abnormal repetitive motor activity:
- Facial movements
- Eye deviations
- Eyelid fluttering
- Lip smacking/sucking
Respiratory alterations
Apnea
Seizure activity:
- Focal or generalized tonic seizures
- Focal or multifocal clonic seizures
- Myoclonic movements
Generalized problems (metabolic, infection, etc.) may present with focal seizures

Older Infants and Children

Generalized seizures:
- Tonic " clonic
- Tonic
- Clonic
- Myoclonic
- Atonic ( "drop " )
- Absence
Partial or focal seizures:
- Simple:
  - Consciousness maintained
- Simple partial seizures:
  - Motor, sensory, and/or cognitive symptoms
  - Motor activity focal: 1 part or side
  - Paresthesias, metallic tastes, and visual or auditory hallucinations
- Complex:
  - Consciousness impaired
  - Complex partial seizure
- Simple partial seizure progresses with impaired consciousness:
  - Aura precedes altered consciousness; auditory, olfactory, or visual hallucination
  - May generalize
Status epilepticus:
- Generalized is most common
- Sustained partial seizures
- Absence seizures
- Persistent confusion; postictal period

History

Determine whether seizures are febrile or afebrile
Determine type of seizure:
- Partial vs. generalized
- Presence of eye findings, aura, movements, cyanosis
- Duration
- State of consciousness, postictal state
- Predisposing conditions/history/family history (syndromes with a genetic component)

Physical Exam

Vital signs, including temperature
Careful neurologic exam, including state of consciousness
Eye, including fundoscopic exam
Skin exam to identify neurocutaneous diseases such as tuberous sclerosis

Diagnosis Tests & Interpretation

Lab

Bedside glucose test
Performed in young infants and those in status epilepticus
Select studies in other children reflecting history and physical exam:
- Electrolytes
- BUN
- Creatinine
- Glucose
- Calcium
- Magnesium
- CBC
- Toxicology screen
Patients on anticonvulsant therapy:
- Drug levels
Febrile seizure:
- Lab studies to evaluate for a serious underlying bacterial infection if suspected

Imaging

Head CT:
- Focal seizure
- New focal neurologic abnormality
- Suspected intracranial hemorrhage or mass lesion
- New-onset status epilepticus without identifiable cause
- Not routinely indicated for 1st afebrile seizure
Lumbar puncture:
- Suspicion of meningitis or encephalitis
- CT 1st if suspect increased intracranial pressure
MRI:
- Rarely urgently indicated for seizures
EEG:
- Generally indicated in children with an afebrile seizure as a predictor of risk of recurrence and to classify the seizure type/epilepsy syndrome
- Postictal slowing seen within 24 " 48 hr of a seizure and may be transient; delay EEG if possible
- Rarely helpful in the acute setting

Differential Diagnosis

Neonates:
- Apnea due to other causes
- Jitters or tremors
- Gastroesophageal reflux
Infants and toddlers:
- Breath-holding spells
- Night terrors
Children and adolescents:
- Migraine headache
- Syncope
- Tics
- Pseudoseizures
- Hysteria

Treatment

Pre-Hospital

Cautions:

Many conditions may be mistaken for seizures (see "Differential Diagnosis, " below)
Immobilize cervical spine if trauma suspected
Check fingerstick glucose or administer dextrose as appropriate

Initial Stabilization/Therapy

ABC support if actively seizing
Airway:
- Oxygen/monitor pulse oximetry
- Nasopharyngeal airway preferred over oral airway
- Bag valve " mask support if hypoventilating or persistently hypoxic
- Intubation if seizures are refractory and bag valve " mask support is unsuccessful
IV access:
- If hypoglycemic, give dextrose
Maintain spine precautions if trauma suspected

Airway and breathing must be stabilized concurrent with management of ongoing seizures if present
Early treatment of long-lasting seizure is critical in reducing potential morbidity, including brain damage

Ed Treatment/Procedures

Status Epilepticus

Benzodiazepine:
- When treating IV lorazepam is preferred due to its longer duration of action
- Valium is acceptable
- If IV access is not available:
  - Buccal midazolam (most convenient)
  - Intranasal lorazepam
  - Per rectum diazepam
Phenytoin:
- If benzodiazepines fail
- For longer-term control
- Fosphenytoin easier to administer
Phenobarbital:
- Use if benzodiazepines and phenytoin fail to break the seizure
- Risk of respiratory depression greatly increases if a benzodiazepine has also been given
Alternative therapies in the event of refractory status epilepticus
Consultation appropriate:
- Paraldehyde (per rectum)
- Barbiturate coma:
  - Barbiturate (pentobarbital) coma requires intubation and EEG monitoring to be sure the seizure is suppressed
  - Associated hypotension
- General anesthesia:
  - A final resort
  - Continuous EEG is needed to be sure the seizure is abolished
Neonates:
- Phenobarbital is an acceptable 1st-line therapy
- Preferred maintenance drug

Note: Aggregate response to 2nd- and 3rd-line agents is <10%

Medication

D10: 5 mL/kg IV for neonates
D25: 2 mL/kg IV for children
Diazepam: 0.2 mg/kg IV (max. 10 mg); 0.2 " 0.5 mg/kg PR (max. 20 mg)
Fosphenytoin: 20 mg/kg IV over 20 min
Lorazepam: 0.1 mg/kg IV, IN (max. 5 mg)
Midazolam: 0.05 " 0.1 mg/kg IV; 0.2 mg/kg buccal/IN/IM (max. 7.5 mg)
Pentobarbital: 3 " 5 mg/kg IV over 1 " 2 hr; maintenance: 1 " 3 mg/kg/h IV; monitor for respiratory depression
Phenobarbital: 15 " 20 mg/kg IV over 20 min; monitor for respiratory depression
Phenytoin: 15 " 20 mg/kg IV slowly over 30 " 45 min

Follow-Up

Disposition

Admission Criteria

ICU:
- Active status epilepticus, intubated, or persistent mental status changes
- Repetitive seizures in narrow time frame
Inpatient unit:
- Status epilepticus resolved in the ED
- Underlying cause of seizure unresolved, uncontrolled, or poorly understood
- Intracranial hemorrhage
- Mass lesion
- Meningitis/encephalitis
- Drug
- Toxin ingestions

Discharge Criteria

The child is alert with normal mental status and neurologic exam
No evidence of an underlying cause requiring hospitalization
Reliable parent or caregiver
Home telephone

Issues for Referral
Unresponsive or repetitive seizures

Follow-Up Recommendations

Provide seizure precautions and aftercare instructions
Follow-up with PCP or pediatric neurologist

Pearls and Pitfalls

Phenobarbital is the preferred treatment for theophylline-induced seizures, poor response to benzodiazepines and phenytoin
Consider buccal or intranasal benzodiazepine if no IV access

Additional Reading

Abend NS, Huh JW, Helfaer MA, et al. Anticonvulsant medications in the pediatric emergency room and intensive care unit. Pediatr Emerg Care. 2008;24(10):705 " 718.
Barata I. Pediatric seizures. Crit Decisions Emerg Med. 2005;19:1 " 10.
Blumstein MD, Friedman MJ. Childhood seizures. Emerg Med Clin North Am. 2007;25:1061 " 1086.
Lagae L. Clinical practice: The treatment of acute convulsive seizures in children. Eur J Pediatr. 2011;170:413 " 418.
Sofou K, Kristj ‘nsd ³ttir R, Papachatzakis NE, et al. Management of prolonged seizures and status epilepticus in childhood: A systematic review. J Child Neurol. 2009;24(8):918 " 926.
Yoshikawa H. First-line therapy for theophylline-associated seizures. Acta Neurol Scand. 2007;115:57 " 61.

Codes

ICD9

780.31 Febrile convulsions (simple), unspecified
780.33 Post traumatic seizures
780.39 Other convulsions

ICD10

R56.00 Simple febrile convulsions
R56.1 Post traumatic seizures
R56.9 Unspecified convulsions
G40.509 Epileptic seiz rel to extrn causes, not ntrct, w/o stat epi

SNOMED

91175000 seizure (finding)
41497008 Febrile convulsion (finding)
437871001 Seizure after head injury (finding)
371022006 Seizures due to metabolic disorder (disorder)
230434009 Seizures in response to acute event (disorder)
371115001 Seizures complicating infection (disorder)
443410001 Childhood seizure (finding)

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