Seizure (peds)
This page is for pediatric patients. For adult patients, see: seizure.
Background
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
Evaluation
Seizure with a Fever
- See Febrile 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 MRI
- Consider emergent imaging (CT head) for 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
- Less often have generalized tonic-clonic seizures
- 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 antimicrobials (including acyclovir)
- Phenobarbital is first-line treatment for most neonatal seizures [5]
- Consider pyridoxine and folic acid if unresponsive to treatment[6]
- 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, 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
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
- If prolonged postictal state or longer than usual consider nonconvulsive status
- Management
Management
Initial management of pediatric status epilepticus
Timeline | General Considerations | Seizure Treatment |
0-5 minutes |
|
|
5-10 minutes |
|
|
10-15 minutes |
|
|
15-30 minutes |
|
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>30 minutes |
|
|
^May be ineffective for toxin-induced seizures and contraindicated in cocaine toxicity
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 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 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
- 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]
Pediatric Anticonvulsants Table
Drug | Dose | Infusion Rate (Minutes) | Age | Comments/Cautions |
---|---|---|---|---|
Levetiracetam |
|
≥5 | Any | Most commonly used agent |
Fosphenytoin |
|
≥10 | Any | Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures |
Valproic acid |
|
≥10 | ≥2 years | Caution in patients with liver dysfunction, mitochondrial disease, urea disorder, thrombocytopenia, or unexplained developmental delay |
Phenytoin |
|
≥20 | Any | Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures |
Phenobarbital |
|
≥20 | <6 months | First line for most neonatal seizures. Respiratory depression, especially in combination with benzodiazepines |
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
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
- ↑ Shellhaas, R. Treatment of neonatal seizures. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com (Accessed on October 28, 2023.)
- ↑ Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.
- ↑ 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