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
  • Lateral tongue biting - 100% specificity
  • Incontinence

Differential Diagnosis

Pediatric seizure

Evaluation

Seizure with a Fever

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
  • 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
  • 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:
  • 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
  • Imaging
    • Obtain shunt series and head CT or 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

Timeline General Considerations Seizure Treatment
0-5 minutes
  • Supportive care
    • ABC's
    • Maintain airway; suction, jaw thrust
    • Provide O2 via positive pressure ventilation with BVM/Mapleson
      • Likely apneic/hypoventilating/hypercapneic
      • Only apply CPAP or a non-rebreather if patient stops seizing and has adequate chest rise
  • Establish IV/IO access
  • Check blood glucose
  • If fever, acetaminophen 15 mg/kg rectally
  • Benzodiazepine: first dose
    • IV/IO access established
      • Lorazepam 0.1 mg/kg IV (max 4 mg) if IV/IO access, OR
      • Diazepam 0.2 mg/kg IM (max 10 mg) if no access
    • IV or IO access not achieved within 3 minutes:
      • Buccal midazolam 0.2 mg/kg (max 10 mg), OR
      • IM midazolam 0.2 mg/kg (max 10 mg), OR
      • Rectal diazepam (Diastat gel or injection solution given rectally) 0.5 mg/kg (max 20 mg)
5-10 minutes
  • Give antibiotics if concern for sepsis or meningitis
  • POC electrolytes, if available
  • Benzodiazepine: second dose
10-15 minutes
  • All equally efficacious for status epilepticus
  • Levetiracetam is preferred given quick administration, favorable side effect profile, and less drug interactions
  • Do not combine Phenytoin and Fosphenytoin
  • Antiepileptic: first therapy
    • Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min, OR
    • Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR
    • Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR
    • Phenobarbital 20 mg/kg IV/IO, (max 1 g) over 20 min, (expect respiratory depression with apnea)¥
15-30 minutes
  • Consider intubation, if not already performed
    • Consider NG tube to decompress stomach prior to intubation
  • Pediatric neurology consultation
  • Antiepileptic: second therapy (if medication not already given)
    • Fosphenytoin^ 20 mg PE/kg IV/IO (max 1500mg) over 10 min, OR
    • Valproate 40 mg/kg IV/IO (max 3000mg) over 10 min, OR
    • Phenobarbital 20 mg/kg IV/IO (max 1 g) over 20 min
      • 10 mg/kg if phenobarbital already given, OR
    • Levetiracetam 60 mg/kg IV/IO (max 4500mg) over 5 min
  • If isoniazid toxicity suspected, pyridoxine
    • Infants (<1 year): 100 mg IV or IO in
    • Otherwise 70 mg/kg IV or IO (max = 5 g)
>30 minutes
  • Intubate patient, if not already performed
  • Consult referral site / PICU for admission and continuous EEG
  • Antiepileptic: third therapy
    • Midazolam 0.2mg/kg IV bolus (max 10mg), followed by 0.2mg/kg/hr (max 10mg/hr) infusion drip
    • Increase infusion rate by 0.2mg/kg/hr (max 10mg/hr) every 10 minutes until burst suppression or max dose of 2mg/kg/hr (max 100mg/hr)

^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
    • 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

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
  • 60 mg/kg/dose IV/IO
  • MAX: 4500 mg/dose
≥5 Any Most commonly used agent
Fosphenytoin
  • 20 mg phenytoin equivalent (PE)/kg/dose IV/IO/IM
  • MAX: 1000 PE/dose
≥10 Any Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures
Valproic acid
  • 40 mg/kg/dose IV/IO
  • MAX: 3000 mg/dose
≥10 ≥2 years Caution in patients with liver dysfunction, mitochondrial disease, urea disorder, thrombocytopenia, or unexplained developmental delay
Phenytoin
  • 20 mg/kg/dose IV/IO
  • MAX: 1000 mg/dose
≥20 Any Choose alternate drug if on phenytoin at home; may decrease BP/HR; not for toxin-induced seizures
Phenobarbital
  • 20 mg/kg/dose IV/IO
  • MAX: 1000 mg/dose
≥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

  1. 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.
  2. Epilepsia 2015; 56:1515-1523.
  3. 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.
  4. Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
  5. Shellhaas, R. Treatment of neonatal seizures. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com (Accessed on October 28, 2023.)
  6. Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.
  7. 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.
  8. 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