View source for Seizure (peds)

{{Peds top}} [[seizure]].''
==Background==
{{Seizure types}}
{{Clinical features seizure}}

==Differential Diagnosis==
{{Pediatric seizure DDX}}

==Evaluation==
===Seizure with a Fever===
*See [[Febrile Seizure]]

===[[first-time seizure|First-Time Afebrile Seizure]]===
*If patient returns to baseline no labs/imaging necessarily indicated
**Head to toe exam - abusive head trauma may precipitate seizure and requires emergent imaging
**Glucose
**Consider chemistry, Mg
**Consider [[EKG]] if concerned for cardiac [[arrhythmia]] 
*[[LP]] only necessary if concern for [[meningitis (peds)]]
*Neuroimaging
**Preferred test is outpatient [[brain MRI|MRI]]
**Consider emergent imaging ([[CT head]]) for [[focal neuro|focal deficit]], no return to baseline
*40% have 2nd seizure

===Neonatal Seizure===
*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]], [[LP]] for CSF (including HSV), utox (withdrawal)
**Consider neuroimaging if concern for abuse, [[intracranial hemorrhage]], mass
**Consider [[lactate]], ammonia if concern for [[inborn errors of metabolism]]
*Treatment
**Start IV [[pediatric antibiotics|antimicrobials]] (including [[acyclovir]])
**Phenobarbital is first-line treatment for most neonatal seizures <ref> Shellhaas, R. Treatment of neonatal seizures. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com (Accessed on October 28, 2023.) </ref>
**Consider [[pyridoxine]] and [[folic acid]] if unresponsive to treatment<ref>Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.</ref>
***Pyridoxal phosphate 10mg/kg/dose q2h x 2 doses
***If persistent, folinic acid 5mg q6h x 2 doses
***EEG monitoring during this period is helpful

===Epileptic Seizures===
*Epilepsy = 2 or more seizures with out acute provocation (fever, trauma)
*Often due to patient "outgrowing" their dosage
*Check levels:
**See [[anticonvulsant levels and reloading]]
**[[Phenytoin]], [[carbamazepine]], [[valproic acid]]
***If low consider medication non-adherence, "outgrowing" dose, vomiting, med interaction
*Patients with epilepsy may have lower seizure threshold with febrile illness
**Usually can limit ED work up to fever evaluation

===Seizure with [[VP shunt]]===
*Consider underlying epilepsy, [[VP shunt malfunction|shunt malfunction]], [[VP shunt infections|CNS infection]]
**If patient has fever, seizure more likely secondary to infection than malfunction
***Consult pediatric neurosurgeon to tap the shunt
*Imaging
**Obtain shunt series and [[head CT]] or [[brain MRI|MRI]] to evaluate for increased ventricular size

===Seizure with [[Pediatric Head Trauma]]===
*"Impact seizures" (seizures that occurs within minutes of head trauma)
**Not associated with severe head injuries
*Seizures that occur after this time more likely to represent intracranial injury
*Abusive head trauma should always be considered in differential

===[[Status Epilepticus]]===
*Seizure or recurrent seizure lasting >5min with out 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, [[LFTs]], ?CSF, ?neuroimaging
**[[Intubate]] if evidence of apnea and persistent hypoxia
**If paralytic used, EEG monitoring should be arranged

==Management==
{{Initial management of pediatric status epilepticus}}

===[[Hypoglycemia (Peds)|Hypoglycemia]]===
*Defined as <50mg/dL 
*All seizing patients with hypoglycemia should be treated with 2 mL/kg 25% dextrose

===[[Hyponatremia]]===
*Consider as cause of seizure, especially if Na <120 mEq/L 
*Goal of therapy is to correct quickly to >120, slowly thereafter 
**In actively seizing patient, treatment of choice is [[hypertonic saline|3% NaCl]] 
***[[hypertonic saline|3% NaCl]] (513 mEq/1000 mL) 
****Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min '''OR''' 
***3% NaCl: 4-6 mL/kg over 20min 
**If no seizure activity but Na <120 start 4-6 mL/kg 3% NaCl or 20 mL/kg of NS over 1hr 
***Check Na level after bolus to see if second bolus is necessary 
**If 3% unavailable, start NS 20mL/kg

===[[Hypocalcemia]]===
*Administer 10% [[calcium gluconate]] 0.3 mL/kg over 5-10min

===Other===
*Consider [[Pyridoxine]] (vitamin B6) 1g per g of [[INH]] ingested  (in D5W IV over 30 min) <ref> Minns AB, Ghafouri N, Clark RF. Isoniazid-induced status epilepticus in a pediatric patient after inadequate pyridoxine therapy. Pediatr Emerg Care. 2010; 26(5):380-1. </ref>
*Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective <ref>Pyridoxine dependent seizures a wider clinical spectrum. Archives of Disease in Childhood.1983 (58) 415-418. http://adc.bmj.com/content/58/6/415.full.pdf</ref>

{{Pediatric anticonvulsants}}

==Disposition==
If negative workup
*EEG and MRI as outpatient
*Diastat ([[diazepam]]) Rectal Kit 
**2-5 yrs:  0.5mg/kg
**6-11 yrs: 0.3mg/kg
**12+ yrs:  0.2mg/kg

==See Also==
*[[Seizure]]
*[[Febrile Seizure]]
*[[Seizure Levels and Reloading]]
*[[Status epilepticus (peds)]]

==External Links==
*[http://pemplaybook.org/podcast/131/ Pediatric Emergency Playbook Podcast - Carpe Cerebrum: Seize the Brain]
**[http://traffic.libsyn.com/pemplaybook/Pediatric_Status_Epilepticus.mp3 Carpe Cerebrum: Seize the Brain (mp3)]

==References==
<references/>

[[Category:Pediatrics]]
[[Category:Neurology]]