Seizure (peds): Difference between revisions

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{{Peds top}} [[seizure]].''
==Background==
==Background==
*Consider neuroimaging for new-onset focal seizure
*Todd paralysis
**Temporary focal deficit up to 36 hr post-seizure
*Lateral tongue biting - 100% sp
{{Seizure types}}
{{Seizure types}}
{{Clinical features seizure}}
{{Clinical features seizure}}


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{{Pediatric seizure DDX}}
{{Pediatric seizure DDX}}


==Diagnosis==
==Evaluation==
===Seizure with a Fever===
===Seizure with a Fever===
*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, utox
**Head to toe exam - abusive head trauma may precipitate seizure and requires emergent imaging
*LP only necessary if concern for meningitis
**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 outpt MRI
**Preferred test is outpatient [[brain MRI|MRI]]
**Consider emergent imaging for focal deficit, no return to baseline
**Consider emergent imaging ([[CT head]]) for [[focal neuro|focal deficit]], no return to baseline
*40% have 2nd sz
*40% have 2nd seizure


===Neonatal Seizure===
===Neonatal Seizure===
*Often subtle, focal, poor prognosis
*Often subtle, focal, poor prognosis
**Less often have generalized tonic-clonic seizures
**Less often have generalized tonic-clonic seizures
***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, ICH, mass
**Consider neuroimaging if concern for abuse, [[intracranial hemorrhage]], mass
**Consider lactate, ammonia if concern for errors of metabolism
**Consider [[lactate]], ammonia if concern for [[inborn errors of metabolism]]
*Treatment
*Treatment
**Start IV abx (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>
**Phenobarbital is first-line treatment for most neonatal seizures <ref> Shellhaas, R. Treatment of neonatal seizures. In: UpToDate, Post TW (Ed), Wolters Kluwer. https://www.uptodate.com (Accessed on October 28, 2023.) </ref>
***x2 doses pyridoxal phosphate 10 mg/kg/dose 2 hrs apart
**Consider [[pyridoxine]] and [[folic acid]] if unresponsive to treatment<ref>Robert Surtees and Nicole Wolf. Treatable neonatal epilepsy. Arch Dis Child. 2007 Aug; 92(8): 659–661.</ref>
***If persistent, x2 doses of folinic acid 5 mg 6 hrs apart
***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
***EEG monitoring during this period is helpful


===Epileptic Seizures===
===Epileptic Seizures===
*Epilepsy = 2 or more sz 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:
**Phenytoin, carbamazepine, valproic acid
**See [[anticonvulsant levels and reloading]]
***If low consider non-compliance, "outgrowing," vomiting, med interaction
**[[Phenytoin]], [[carbamazepine]], [[valproic acid]]
*Pts with epilepsy may have lower sz threshold with febrile illness
***If low consider medication non-adherence, "outgrowing" dose, vomiting, med interaction
**Usually can limit ED w/u to fever evaluation
*Patients with epilepsy may have lower seizure threshold with febrile illness
**Usually can limit ED work up to fever evaluation


===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 incr ventricular size
**Obtain shunt series and [[head CT]] or [[brain MRI|MRI]] to evaluate for increased ventricular size


===Seizure with Trauma===
===Seizure with [[Pediatric Head Trauma]]===
*"Impact seizures" (sz that occurs w/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
*Sz 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]]===
*Seizure or recurrent sz lasting >5min with out regaining consciousness
*Seizure or recurrent seizure lasting >5min with out regaining consciousness
**If prolonged postictal state or longer than usual consider nonconvulsive status
**If prolonged postictal state or longer than usual consider nonconvulsive status
***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 e/o apnea and persistent hypoxia
**[[Intubate]] if evidence of apnea and persistent hypoxia
**If use paralytic EEG monitoring should be arranged
**If paralytic used, EEG monitoring should be arranged


==Management==
==Management==
===1st Line===
{{Initial management of pediatric status epilepticus}}
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif; width: 522px; height: 339px;"
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Drug<ref> LaRoche SM, Helmers SL. The New Antiepileptic Drugs: Scientific Review. JAMA. 2004;291:605-614. </ref>
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Route
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Dose*
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Maximum
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Onset of Action
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Duration of Action
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | [[Lorazepam]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV, IO, IN<br>&nbsp;
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 4 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 12–24 h
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IM
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 4 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–30 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 12–24 h
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | [[Diazepam]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV, IO
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1–0.3 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 10 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–60 min
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | PR
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.5 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 20 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–60 min
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="4" class="font12" | [[Midazolam]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV, IO
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1–0.2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 4 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–6 h
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IM
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 10 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5–15 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–6 h
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IN
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 10 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–6 h
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Buccal<br>&nbsp;
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.5 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 10 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3–5 min
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–6 h
|}
 
===2nd Line ===


*If sz persists for another 5 min after 2 doses of benzos switch to fosphenytoin or phenobarbital
===[[Hypoglycemia (Peds)|Hypoglycemia]]===
**Fosphenytoin is usually preferred 2nd line agent&nbsp;
*Defined as <50mg/dL  
**Consider phenobarb over fosphenytoin if febrile illness, &lt;2yr
 
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif; width: 548px; height: 211px;"
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Drug
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Route
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Loading Dose
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Repeat Dose
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | Maximum
! bgcolor="#ffffff" align="left" valign="top" rowspan="1" | IV Infusion
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Fosphenytoin]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV, IM
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–20 mg/kg PE
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5–10 mg/kg PE
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 30 mg/kg PE
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3 mg/kg/min PE
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Phenobarbital]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–20 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5–10 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 40 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–30 mg/min
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Valproic acid]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 20 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15–20 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 40 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5 mg/kg/hr
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Levetiracetam]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 20–30 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | —
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3 grams
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | —
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Pentobarbital]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5–15 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 15 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.5–5.0 mg/kg/hr
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Propofol]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.5–2.0 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.5–1.0 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 5 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1.5–4.0 mg/kg/hr
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | [[Midazolam]]
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | IV
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1–0.2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.1–0.2 mg/kg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 10 mg
| bgcolor="#ffffff" align="left" valign="top" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.05–0.4 mg/kg/hr
|}
 
===3rd Line ===
*Consider Valproic acid 20mg/kg over 1-5min; then infusion of 5mg/kg/hr
 
===[[Hypoglycemia (Peds)|Hypoglycemia]] ===
*Defined as &lt;50 mg/dL  
*All seizing patients with hypoglycemia should be treated with 2 mL/kg 25% dextrose
*All seizing patients with hypoglycemia should be treated with 2 mL/kg 25% dextrose


===[[Hyponatremia]]===
===[[Hyponatremia]]===
*Consider as cause of sz, esp if Na &lt;120 mEq/L  
*Consider as cause of seizure, especially if Na <120 mEq/L  
*Goal of therapy is to correct quickly to &gt;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  
**If no sz activity but Na &lt;120 start 4-6 mL/kg 3% NaCl or 20 mL/kg of NS over 1hr  
**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  
***Check Na level after bolus to see if second bolus is necessary  
**If 3% unavailable start NS 20mL/kg
**If 3% unavailable, start NS 20mL/kg


===[[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>
{{Pediatric anticonvulsants}}


==Disposition==
==Disposition==
If negative workup
If negative workup
*EEG and MRI outpt Rx
*EEG and MRI as outpatient
*Diastat ([[diazepam]]) Rectal Kit  
*Diastat ([[diazepam]]) Rectal Kit  
**2-5 yrs:  0.5 mg/kg
**2-5 yrs:  0.5mg/kg
**6-11 yrs: 0.3 mg/kg
**6-11 yrs: 0.3mg/kg
**12+ yrs:  0.2 mg/kg
**12+ yrs:  0.2mg/kg


==See Also==
==See Also==
Line 236: Line 110:
*[[Febrile Seizure]]
*[[Febrile Seizure]]
*[[Seizure Levels and Reloading]]
*[[Seizure Levels and Reloading]]
*[[Status epilepticus (peds)]]


==External Links==
==External Links==

Latest revision as of 16:18, 28 October 2023

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