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; More recent terms suggested by the ILAE (International League Against Epilepsy) task Force.

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

• 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
    • Meningitis
    • Encephalitis
    • CNS abscess
    • Intracranial hemorrhage
    • Neurocysticercosis
  • Increased ICP
    • Seizure with VP shunt
    • Hydrocephalus
    • Intracranial mass
  • Toxicologic
    • Alcohol withdrawal
    • Benzodiazepine withdrawal
    • Toxic ingestion
  • Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia
  • Pyridoxine responsive seizure
  • 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
• 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
  • Consider pyridoxine and folic acid if unresponsive to treatment
    • 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
• 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

• 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)
• Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective

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

• Seizure
• Febrile Seizure
• Seizure Levels and Reloading
• Status epilepticus (peds)

External Links

• Pediatric Emergency Playbook Podcast - Carpe Cerebrum: Seize the Brain
  • Carpe Cerebrum: Seize the Brain (mp3)