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

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
  • 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
  • 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
  • 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
  • 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
    • 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

Hypocalcemia

  • Administer 10% calcium gluconate 0.3 mL/kg over 5-10min

See Also

Source

  • Tintinali