Seizure (peds)

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This page refers to pediatric patients; see seizure for adult patients.

Background

  • Todd paralysis
    • Temporary focal deficit up to 36 hr post-seizure
  • Lateral tongue biting - 100% specificity

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
    • With sensory symptoms
    • With autonomic symptoms or signs
    • With psychic symptoms (including aura)
  • 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
  • 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)
    • Typical absence seizures
    • Atypical absence seizures
  • Myoclonic seizure
  • Clonic seizures
  • Tonic seizures
  • Tonic–clonic seizures (Older term: grand mal)
  • Atonic seizures

Clinical Features

  • Abrupt onset, may be unprovoked
  • Brief duration (typically <2min)
  • AMS
  • Jerking of limbs
  • Postictal drowsiness/confusion

Differential Diagnosis

Pediatric seizure

Evaluation

Seizure with a Fever

First-Time Afebrile Seizure

  • If patient returns to baseline no labs/imaging necessarily indicated
    • Consider glucose, chemistry,
  • LP only necessary if concern for meningitis (peds)
  • EEG should be performed within 24-48hr
  • Neuroimaging
    • Preferred test is outpatient MRI
    • Consider emergent imaging 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
  • Work-up
    • CBC, chemistry, UA, 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)
    • Consider B6 and folic acid responsive etiologies unresponsive to benzos[4]
      • 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 of:
  • 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 in minutes of head trauma)
    • Not associated with severe head injuries
  • Seizures that occur after this time more likely to represent intracranial injury

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, LFT, ?CSF, ?neuroimaging
    • Intubate if evidence of apnea and persistent hypoxia
    • If paralytic used, EEG monitoring should be arranged

Management

1st Line

Drug[5] Route Dose* Maximum Onset of Action Duration of Action
Lorazepam IV, IO, IN
  		0.1mg/kg 4mg 1–5 min 12–24 h
IM 0.1mg/kg 4mg 15–30 min 12–24 h
Diazepam IV, IO 0.1–0.3mg/kg 10mg 1–5 min 15–60 min
PR 0.5mg/kg 20mg 3–5 min 15–60 min
Midazolam IV, IO 0.1–0.2mg/kg 4mg 1–5 min 1–6 h
IM 0.2mg/kg 10mg 5–15 min 1–6 h
IN 0.2mg/kg 10mg 1–5 min 1–6 h
Buccal
  		0.5mg/kg 10mg 3–5 min 1–6 h

2nd Line

  • If seizure persists for another 5 min after 2 doses of benzodiazepines 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 15–20mg/kg PE 5–10mg/kg PE 30mg/kg PE 3mg/kg/min PE
Phenobarbital IV 15–20mg/kg 5–10mg/kg 40mg/kg 1–30mg/min
Valproic acid IV 20mg/kg 15–20mg/kg 40mg/kg 5mg/kg/hr
Levetiracetam IV 20–30mg/kg — 3 grams —
Pentobarbital IV 5–15mg/kg 1–2mg/kg 15mg/kg 0.5–5.0mg/kg/hr
Propofol IV 0.5–2.0mg/kg 0.5–1.0mg/kg 5mg/kg 1.5–4.0mg/kg/hr
Midazolam IV 0.1–0.2mg/kg 0.1–0.2mg/kg 10mg 0.05–0.4mg/kg/hr

3rd Line

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

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

  • 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) [6]
  • Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective [7]

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. ↑ Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
  4. ↑ Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.
  5. ↑ LaRoche SM, Helmers SL. The New Antiepileptic Drugs: Scientific Review. JAMA. 2004;291:605-614.
  6. ↑ 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.
  7. ↑ 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
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