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

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/hr
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/hr
Propofol	IV	0.5–2.0 milligrams/kg	0.5–1.0 milligram/kg	5 milligrams/kg	1.5–4.0 milligrams/kg/hr
Midazolam	IV	0.1–0.2 milligram/kg	0.1–0.2 milligram/kg	10 milligrams	0.05–0.4 milligram/kg/hr

3rd Line

• Consider Valproic acid 20mg/kg over 1-5min; then infusion of 5mg/kg/hr

Hypoglycemia

• Defined as <50 mg/dL
• All seizing pts with hypoglycemia should be treated with 2 mL/kg 25% dextrose in water

Hyponatremia

• Consider as cause of sz, esp if Na <120 mEq/L
• Goal of therapy is to correct quickly  to >120, slowly thereafter
  • In actively seizing pt treatment of choice is 3% NaCl
    • 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
  • If 3% unavailable start NS 20mL/kg

Hypocalcemia

• Administer 10% calcium gluconate 0.3 mL/kg over 5-10min

See Also

Febrile Seizure

Source

Tintinali