Seizure (peds)
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Background
- Consider neuroimaging for new-onset focal seizure
- Todd paralysis
- Temporary focal deficit up to 36 hr post-seizure
- Lateral tongue biting - 100% sp
Seizure Types
Classification is based on the international classification from 1981[1]; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.[2]
Focal seizures
(Older term: partial seizures)
- Without impairment in consciousness– (AKA Simple partial seizures)
- With motor signs (ex. facial twiching or rhythmic ipsilateral extremity movements)
- With sensory symptoms (ex. tingling or pereiving a certain smell)
- With autonomic symptoms or signs (ex. tachycardia or diaphoresis)
- With psychic symptoms (including aura, ex. sense of déjà-vu)
- With impairment in consciousness - (AKA Complex Partial Seizures--Older terms: temporal lobe or psychomotor seizures)
- Simple partial onset, followed by impairment of consciousness
- With impairment of consciousness at onset
- These seizures may be accompanied by automatism (such as lip smacking and chewing, hand wringing, patting and rubbing)
- Focal seizures evolving to secondarily generalized seizures
- Simple partial seizures evolving to generalized seizures
- Complex partial seizures evolving to generalized seizures
- Simple partial seizures evolving to complex partial seizures evolving to generalized seizures
Generalized seizures
- Absence seizures (Older term: petit mal; brief dissociative states without postural changes)
- Typical absence seizures
- Atypical absence seizures (last longer and often include more motor involvement)
- Myoclonic seizure (violent muscle contractions)
- Clonic seizures (rhythmic jerking)
- Tonic seizures (stiffening)
- Tonic–clonic seizures (Older term: grand mal)
- Atonic seizures (loss of muscle tone -> drop attacks)
SUDEP[3]
- Sudden Unexpected Death in Epilepsy
- Generalized tonic-clonic seizure is the major risk factor for SUDEP, and seizure freedom is strongly associated with decreased risk
- Annual incidence of SUDEP in children is 1 in 4500
- Incidence in adults is 1 in 1000
Clinical Features
- Abrupt onset, may be unprovoked
- Brief duration (typically <2min)
- AMS
- Jerking of limbs
- Postictal drowsiness/confusion (typically lasting <30 minutes)
- Todd paralysis
- Temporary focal deficit up to 36 hr post-seizure
- Lateral tongue biting - 100% specificity
- Incontinence
Differential Diagnosis
Pediatric seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with or "outgrowing" AEDs
- Non-epileptic seizure
- Febrile seizure
- Brain inflammation
- Increased ICP
- Seizure with VP shunt
- Hydrocephalus
- Intracranial mass
- Toxicologic
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia
- Pyridoxine responsive seizure[4]
- Eclampsia
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Other mimics
- Psychogenic nonepileptic seizure (pseudoseizure)
- Syncope (peds)
- Breath-holding spell
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
- Infantile Spasms/West Syndrome
Diagnosis
Seizure with a Fever
- See Febrile Seizure
First-Time Afebrile Seizure
- If patient 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 Seizure
- Often subtle, focal, poor prognosis
- Less often have generalized tonic-clonic seizures
- Findings include lip smacking, eye deviation, staring, ALTE
- Less often have generalized tonic-clonic seizures
- 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)
- Consider B6 and folic acid responsive etiologies unresponsive to benzos[5]
- x2 doses pyridoxal phosphate 10 mg/kg/dose 2 hrs apart
- If persistent, x2 doses of folinic acid 5 mg 6 hrs apart
- EEG monitoring during this period is helpful
Epileptic Seizures
- Epilepsy = 2 or more sz with out acute provocation (fever, trauma)
- Often due to patient "outgrowing" their dosage
- Check levels of:
- Phenytoin, carbamazepine, valproic acid
- If low consider non-compliance, "outgrowing," vomiting, med interaction
- Phenytoin, carbamazepine, valproic acid
- 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 patient has fever seizure more likely secondary to infection than malfunction
- Consult pediatric neurosurgeon to tap the shunt
- If patient has fever seizure more likely secondary to infection than malfunction
- 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
Status Epilepticus
- Seizure or recurrent sz 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
- If prolonged postictal state or longer than usual consider nonconvulsive status
- Management
- Glucose, chemistry, CBC, LFT, ?CSF, ?neuroimaging
- Intubate if evidence of apnea and persistent hypoxia
- If use paralytic EEG monitoring should be arranged
Management
1st Line
Drug[6] | Route | Dose* | Maximum | Onset of Action | Duration of Action |
---|---|---|---|---|---|
Lorazepam | IV, IO, IN |
0.1 mg/kg | 4 mg | 1–5 min | 12–24 h |
IM | 0.1 mg/kg | 4 mg | 15–30 min | 12–24 h | |
Diazepam | IV, IO | 0.1–0.3 mg/kg | 10 mg | 1–5 min | 15–60 min |
PR | 0.5 mg/kg | 20 mg | 3–5 min | 15–60 min | |
Midazolam | IV, IO | 0.1–0.2 mg/kg | 4 mg | 1–5 min | 1–6 h |
IM | 0.2 mg/kg | 10 mg | 5–15 min | 1–6 h | |
IN | 0.2 mg/kg | 10 mg | 1–5 min | 1–6 h | |
Buccal |
0.5 mg/kg | 10 mg | 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 mg/kg PE | 5–10 mg/kg PE | 30 mg/kg PE | 3 mg/kg/min PE |
Phenobarbital | IV | 15–20 mg/kg | 5–10 mg/kg | 40 mg/kg | 1–30 mg/min |
Valproic acid | IV | 20 mg/kg | 15–20 mg/kg | 40 mg/kg | 5 mg/kg/hr |
Levetiracetam | IV | 20–30 mg/kg | — | 3 grams | — |
Pentobarbital | IV | 5–15 mg/kg | 1–2 mg/kg | 15 mg/kg | 0.5–5.0 mg/kg/hr |
Propofol | IV | 0.5–2.0 mg/kg | 0.5–1.0 mg/kg | 5 mg/kg | 1.5–4.0 mg/kg/hr |
Midazolam | IV | 0.1–0.2 mg/kg | 0.1–0.2 mg/kg | 10 mg | 0.05–0.4 mg/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 patients with hypoglycemia should be treated with 2 mL/kg 25% dextrose
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 patient treatment of choice is 3% NaCl
- 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
- 3% NaCl (513 mEq/1000 mL)
- If no sz 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
- In actively seizing patient treatment of choice is 3% NaCl
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) [7]
- Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective [8]
Disposition
If negative workup
- EEG and MRI outpt Rx
- Diastat (diazepam) Rectal Kit
- 2-5 yrs: 0.5 mg/kg
- 6-11 yrs: 0.3 mg/kg
- 12+ yrs: 0.2 mg/kg
See Also
External Links
References
- ↑ Proposal for revised clinical and electroencephalographic classification of epileptic seizures. From the Commission on Classification and Terminology of the International League Against Epilepsy. Epilepsia 1981; 22:489.
- ↑ Epilepsia 2015; 56:1515-1523.
- ↑ Harden C et al. American Academy of Neurology and the American Epilepsy Society. Practice guideline summary: Sudden unexpected death in epilepsy incidence rates and risk factors. Neurology April 25, 2017 vol. 88 no. 17 1674-1680.
- ↑ Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
- ↑ Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.
- ↑ LaRoche SM, Helmers SL. The New Antiepileptic Drugs: Scientific Review. JAMA. 2004;291:605-614.
- ↑ 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.
- ↑ 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