Doctor123.org

Seizure, Pediatric, Emergency Medicine

Basics

Description

- Metabolic: - Hypoglycemia - Hypocalcemia - Hypo/hypernatremia - Inborn errors of metabolism

- Subtle abnormal repetitive motor activity: - Facial movements - Eye deviations - Eyelid fluttering - Lip smacking/sucking

- Partial or focal seizures: - Simple: - 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

- Status epilepticus: - Generalized is most common - Sustained partial seizures - Absence seizures - Persistent confusion; postictal period

- 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)

- 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

- 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

- Neonates: - Apnea due to other causes - Jitters or tremors - Gastroesophageal reflux

- Infants and toddlers: - Breath-holding spells - Night terrors

- 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

- 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

- 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

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

Etiology

  • Febrile seizures
  • Infection
  • Idiopathic
  • Trauma
  • Toxicologic:IngestionDrug actionDrug withdrawal
  • Metabolic:HypoglycemiaHypocalcemiaHypo/hypernatremiaInborn 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 movementsEye deviationsEyelid flutteringLip smacking/sucking
  • Respiratory alterations
  • Apnea
  • Seizure activity:Focal or generalized tonic seizuresFocal or multifocal clonic seizuresMyoclonic movements
  • Generalized problems (metabolic, infection, etc.) may present with focal seizures

Older Infants and Children

  • Generalized seizures:Tonic " clonicTonicClonicMyoclonicAtonic ( "drop " )Absence
  • Partial or focal seizures:Simple:Simple partial seizures:Motor, sensory, and/or cognitive symptomsMotor activity focal: 1 part or sideParesthesias, metallic tastes, and visual or auditory hallucinationsComplex:Consciousness impairedComplex partial seizureSimple partial seizure progresses with impaired consciousness:Aura precedes altered consciousness; auditory, olfactory, or visual hallucinationMay generalize
  • Status epilepticus:Generalized is most commonSustained partial seizuresAbsence seizuresPersistent confusion; postictal period

History

  • Determine whether seizures are febrile or afebrile
  • Determine type of seizure:Partial vs. generalizedPresence of eye findings, aura, movements, cyanosisDurationState of consciousness, postictal statePredisposing 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:ElectrolytesBUNCreatinineGlucoseCalciumMagnesiumCBCToxicology screen
  • Patients on anticonvulsant therapy:
  • Febrile seizure:Lab studies to evaluate for a serious underlying bacterial infection if suspected

Imaging

  • Head CT:Focal seizureNew focal neurologic abnormalitySuspected intracranial hemorrhage or mass lesionNew-onset status epilepticus without identifiable causeNot routinely indicated for 1st afebrile seizure
  • Lumbar puncture:Suspicion of meningitis or encephalitisCT 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 syndromePostictal slowing seen within 24 " 48 hr of a seizure and may be transient; delay EEG if possibleRarely helpful in the acute setting

Differential Diagnosis

  • Neonates:Apnea due to other causesJitters or tremorsGastroesophageal reflux
  • Infants and toddlers:Breath-holding spellsNight terrors
  • Children and adolescents:Migraine headacheSyncopeTicsPseudoseizuresHysteria

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 oximetryNasopharyngeal airway preferred over oral airwayBag valve " mask support if hypoventilating or persistently hypoxicIntubation 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 actionValium is acceptableIf IV access is not available:Buccal midazolam (most convenient)Intranasal lorazepamPer rectum diazepam
  • Phenytoin:If benzodiazepines failFor longer-term controlFosphenytoin easier to administer
  • Phenobarbital:Use if benzodiazepines and phenytoin fail to break the seizureRisk 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 suppressedAssociated hypotensionGeneral anesthesia:A final resortContinuous EEG is needed to be sure the seizure is abolished
  • Neonates:Phenobarbital is an acceptable 1st-line therapyPreferred 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 changesRepetitive seizures in narrow time frame
  • Inpatient unit:Status epilepticus resolved in the EDUnderlying cause of seizure unresolved, uncontrolled, or poorly understoodIntracranial hemorrhageMass lesionMeningitis/encephalitisDrugToxin 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.

See Also (Topic, Algorithm, Electronic Media Element)

Seizures, Febrile

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)