Seizure (peds)
Background
- Consider neuroimaging for new-onset focal seizure
- Todd paralysis
- Temporary focal deficit up to 36 hr post-seizure
- Lateral tongue biting - 100% sp
Specific Types
Seizure with a Fever
- See Febrile Seizure
First-Time Afebrile Seizure
- If pt returns to baseline no labs/imaging necessarily indicated
- Consider glucose, chemistry, utox
- LP only necessary if concern for meningitis
- EEG should be performed within 24-48hr
- Neuroimaging
- Preferred test is outpt MRI
- Consider emergent imaging for focal deficit, no return to baseline
- 40% have 2nd sz
Neonatal Seizure
- Often subtle, focal, poor prognosis
- Less often have generalized tonic-clonic seizures
- Findings include lip smacking, eye deviation, staring, ALTE
- Less often have generalized tonic-clonic seizures
- Work-up
- CBC, chemistry, UA, CSF (including HSV), utox (withdrawal)
- Consider neuroimaging if concern for abuse, ICH, mass
- Consider lactate, ammonia if concern for errors of metabolism
- Treatment
- Start IV abx (including acyclovir)
Epileptic Seizures
- Epilepsy = 2 or more sz w/o acute provocation (fever, trauma)
- Often due to pt "outgrowing" their dosage
- Check levels of:
- Phenytoin, carbamazepine, valproic acid
- If low consider non-compliance, "outgrowing," vomiting, med interaction
- Phenytoin, carbamazepine, valproic acid
- Pts with epilepsy may have lower sz threshold with febrile illness
- Usually can limit ED w/u to fever evaluation
Seizure with VP Shunt
- Consider underlying epilepsy, shunt malfunction, CNS infection
- If pt has fever seizure more likely 2/2 infection than malfunction
- Consult pediatric neurosurgeon to tap the shunt
- If pt has fever seizure more likely 2/2 infection than malfunction
- Imaging
- Obtain shunt series and head CT or MRI to evaluate for incr ventricular size
Seizure with Trauma
- "Impact seizures" (sz that occurs w/in minutes of head trauma)
- Not associated with severe head injuries
- Sz that occur after this time more likely to represent intracranial injury
Status Epilepticus
- Seizure or recurrent sz lasting >5min w/o regaining consciousness
- If prolonged postictal state or longer than usual consider nonconvulsive status
- Obtain emergency EEG; if not available trial of anticonvulsants appropriate
- If prolonged postictal state or longer than usual consider nonconvulsive status
- Management
- Glucose, chemistry, CBC, LFT, ?CSF, ?neuroimaging
- Intubate if e/o apnea and persistent hypoxia
- If use paralytic EEG monitoring should be arranged
Treatment
1st Line
Drug | Route | Dose* | Maximum | Onset of Action | Duration of Action |
---|---|---|---|---|---|
Lorazepam | IV, IO, IN |
0.1 mg/kg | 4 mg | 1–5 min | 12–24 h |
IM | 0.1 mg/kg | 4 mg | 15–30 min | 12–24 h | |
Diazepam | IV, IO | 0.1–0.3 mg/kg | 10 mg | 1–5 min | 15–60 min |
PR | 0.5 mg/kg | 20 mg | 3–5 min | 15–60 min | |
Midazolam | IV, IO | 0.1–0.2 mg/kg | 4 mg | 1–5 min | 1–6 h |
IM | 0.2 mg/kg | 10 mg | 5–15 min | 1–6 h | |
IN | 0.2 mg/kg | 10 mg | 1–5 min | 1–6 h | |
Buccal |
0.5 mg/kg | 10 mg | 3–5 min | 1–6 h |
2nd Line
- If sz persists for another 5 min after 2 doses of benzos 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 | 15–20 mg/kg PE | 5–10 mg/kg PE | 30 mg/kg PE | 3 mg/kg/min PE |
Phenobarbital | IV | 15–20 mg/kg | 5–10 mg/kg | 40 mg/kg | 1–30 mg/min |
Valproic acid | IV | 20 mg/kg | 15–20 mg/kg | 40 mg/kg | 5 mg/kg/hr |
Levetiracetam | IV | 20–30 mg/kg | — | 3 grams | — |
Pentobarbital | IV | 5–15 mg/kg | 1–2 mg/kg | 15 mg/kg | 0.5–5.0 mg/kg/hr |
Propofol | IV | 0.5–2.0 mg/kg | 0.5–1.0 mg/kg | 5 mg/kg | 1.5–4.0 mg/kg/hr |
Midazolam | IV | 0.1–0.2 mg/kg | 0.1–0.2 mg/kg | 10 mg | 0.05–0.4 mg/kg/hr |
3rd Line
- Consider Valproic acid 20mg/kg over 1-5min; then infusion of 5mg/kg/hr
Hypoglycemia
- Defined as <50 mg/dL
- All seizing pts with hypoglycemia should be treated with 2 mL/kg 25% dextrose
Hyponatremia
- Consider as cause of sz, esp if Na <120 mEq/L
- Goal of therapy is to correct quickly to >120, slowly thereafter
- In actively seizing pt 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
- 3% NaCl (513 mEq/1000 mL)
- If no sz 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
- In actively seizing pt treatment of choice is 3% NaCl
Hypocalcemia
- Administer 10% calcium gluconate 0.3 mL/kg over 5-10min
See Also
Source
- Tintinali