Seizure (peds): Difference between revisions
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*See [[Febrile Seizure]]
*See [[Febrile Seizure]]


===First-Time Afebrile Seizure===
===[[first-time seizure|First-Time Afebrile Seizure]]===
*If patient returns to baseline no labs/imaging necessarily indicated
*If patient returns to baseline no labs/imaging necessarily indicated
**Consider glucose, chemistry, Mg, EKG if concerned for cardiac arrhythmia  
**Head to toe exam - abusive head trauma may precipitate seizure and requires emergent imaging
*LP only necessary if concern for [[meningitis (peds)]]
**Glucose
*EEG should be performed within 24-48hr
**Consider chemistry, Mg
**Consider [[EKG]] if concerned for cardiac [[arrhythmia]]
*[[LP]] only necessary if concern for [[meningitis (peds)]]
*Neuroimaging
*Neuroimaging
**Preferred test is outpatient MRI
**Preferred test is outpatient [[brain MRI|MRI]]
**Consider emergent imaging (CT head) for focal deficit, no return to baseline
**Consider emergent imaging ([[CT head]]) for [[focal neuro|focal deficit]], no return to baseline
*40% have 2nd seizure
*40% have 2nd seizure


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***Findings include lip smacking, eye deviation, staring, [[ALTE]]
***Findings include lip smacking, eye deviation, staring, [[ALTE]]
*Work-up
*Work-up
**CBC, chemistry, UA, CSF (including HSV), utox (withdrawal)
**CBC, chemistry, [[UA]], [[LP]] for CSF (including HSV), utox (withdrawal)
**Consider neuroimaging if concern for abuse, [intracranial hemorrhage]], mass
**Consider neuroimaging if concern for abuse, [[intracranial hemorrhage]], mass
**Consider lactate, ammonia if concern for [[inborn errors of metabolism]]
**Consider [[lactate]], ammonia if concern for [[inborn errors of metabolism]]
*Treatment
*Treatment
**Start IV antimicrobials (including acyclovir)
**Start IV [[pediatric antibiotics|antimicrobials]] (including [[acyclovir]])
**Consider B6 and folic acid responsive etiologies unresponsive to benzos<ref>Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.</ref>
**Consider [[pyridoxine]] and [[folic acid]] if unresponsive to benzos<ref>Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.</ref>
***Pyridoxal phosphate 10mg/kg/dose q2h x 2 doses
***Pyridoxal phosphate 10mg/kg/dose q2h x 2 doses
***If persistent, folinic acid 5mg q6h x 2 doses
***If persistent, folinic acid 5mg q6h x 2 doses
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*Epilepsy = 2 or more seizures with out acute provocation (fever, trauma)
*Epilepsy = 2 or more seizures with out acute provocation (fever, trauma)
*Often due to patient "outgrowing" their dosage
*Often due to patient "outgrowing" their dosage
*Check levels of:
*Check levels:
**See [[anticonvulsant levels and reloading]]
**[[Phenytoin]], [[carbamazepine]], [[valproic acid]]
**[[Phenytoin]], [[carbamazepine]], [[valproic acid]]
***If low consider medication non-adherence, "outgrowing" dose, vomiting, med interaction
***If low consider medication non-adherence, "outgrowing" dose, vomiting, med interaction
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===Seizure with [[VP shunt]]===
===Seizure with [[VP shunt]]===
*Consider underlying epilepsy, shunt malfunction, CNS infection
*Consider underlying epilepsy, [[VP shunt malfunction|shunt malfunction]], [[VP shunt infections|CNS infection]]
**If patient has fever seizure more likely secondary to infection than malfunction
**If patient has fever, seizure more likely secondary to infection than malfunction
***Consult pediatric neurosurgeon to tap the shunt
***Consult pediatric neurosurgeon to tap the shunt
*Imaging
*Imaging
**Obtain shunt series and head CT or MRI to evaluate for increased ventricular size
**Obtain shunt series and [[head CT]] or [[brain MRI|MRI]] to evaluate for increased ventricular size


===Seizure with [[Pediatric Head Trauma]]===
===Seizure with [[Pediatric Head Trauma]]===
*"Impact seizures" (seizures that occurs within in minutes of head trauma)
*"Impact seizures" (seizures that occurs within minutes of head trauma)
**Not associated with severe head injuries
**Not associated with severe head injuries
*Seizures that occur after this time more likely to represent intracranial injury
*Seizures that occur after this time more likely to represent intracranial injury
*Abusive head trauma should always be considered in differential


===[[Status Epilepticus]]===
===[[Status Epilepticus]]===
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***Obtain emergency EEG; if not available, trial of anticonvulsants appropriate
***Obtain emergency EEG; if not available, trial of anticonvulsants appropriate
*Management
*Management
**Glucose, chemistry, CBC, LFT, ?CSF, ?neuroimaging
**Glucose, chemistry, CBC, [[LFTs]], ?CSF, ?neuroimaging
**Intubate if evidence of apnea and persistent hypoxia
**[[Intubate]] if evidence of apnea and persistent hypoxia
**If paralytic used, EEG monitoring should be arranged
**If paralytic used, EEG monitoring should be arranged


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*Consider as cause of seizure, especially if Na <120 mEq/L  
*Consider as cause of seizure, especially if Na <120 mEq/L  
*Goal of therapy is to correct quickly to >120, slowly thereafter  
*Goal of therapy is to correct quickly to >120, slowly thereafter  
**In actively seizing patient, treatment of choice is 3% NaCl  
**In actively seizing patient, treatment of choice is [[hypertonic saline|3% NaCl]]
***3% NaCl (513 mEq/1000 mL)  
***[[hypertonic saline|3% NaCl]] (513 mEq/1000 mL)  
****Na deficit in total mEq = [(wt in kg)x(130 – serum Na level)x0.6] over 20min '''OR'''  
****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: 4-6 mL/kg over 20min  
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===[[Hypocalcemia]]===
===[[Hypocalcemia]]===
*Administer 10% calcium gluconate 0.3 mL/kg over 5-10min
*Administer 10% [[calcium gluconate]] 0.3 mL/kg over 5-10min


===Other===
===Other===
*Consider [[Pyridoxine]] (vitamin B6) 1g per g of INH ingested  (in D5W IV over 30 min) <ref> 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. </ref>
*Consider [[Pyridoxine]] (vitamin B6) 1g per g of [[INH]] ingested  (in D5W IV over 30 min) <ref> 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. </ref>
*Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective <ref>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</ref>
*Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective <ref>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</ref>


Revision as of 15:36, 3 October 2019

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

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)
    • Consider pyridoxine and folic acid if unresponsive to benzos[5]
      • 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

1st Line

Drug[6] 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

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 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. ↑ Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.
  6. ↑ LaRoche SM, Helmers SL. The New Antiepileptic Drugs: Scientific Review. JAMA. 2004;291:605-614.
  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
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