DESCRIPTION 
Sudden, abnormal discharges of neurons resulting in a change in behavior or function
ETIOLOGY
[Outline]
SIGNS AND SYMPTOMS
Neonates
- Subtle abnormal repetitive motor activity:
- Facial movements
- Eye deviations
- Eyelid fluttering
- Lip smacking/sucking
- Respiratory alterations
- Apnea
- Seizure activity:
- Focal or generalized tonic seizures
- Focal or multifocal clonic seizures
- Myoclonic movements
- Generalized problems (metabolic, infection, etc.) may present with focal seizures
Older Infants and Children
- Generalized seizures:
- Tonic–clonic
- Tonic
- Clonic
- Myoclonic
- Atonic ("drop")
- Absence
- Partial or focal seizures:
- Simple:
- Simple partial seizures:
- Motor, sensory, and/or cognitive symptoms
- Motor activity focal: 1 part or side
- Paresthesias, metallic tastes, and visual or auditory hallucinations
- Complex:
- Consciousness impaired
- Complex partial seizure
- Simple partial seizure progresses with impaired consciousness:
- Aura precedes altered consciousness; auditory, olfactory, or visual hallucination
- May generalize
- Status epilepticus:
- Generalized is most common
- Sustained partial seizures
- Absence seizures
- Persistent confusion; postictal period
History
- Determine whether seizures are febrile or afebrile
- Determine type of seizure:
- Partial vs. generalized
- Presence of eye findings, aura, movements, cyanosis
- Duration
- State of consciousness, postictal state
- Predisposing conditions/history/family history (syndromes with a genetic component)
Physical Exam
- Vital signs, including temperature
- Careful neurologic exam, including state of consciousness
- Eye, including fundoscopic exam
- Skin exam to identify neurocutaneous diseases such as tuberous sclerosis
DIAGNOSIS TESTS & INTERPRETATION
Lab
- Bedside glucose test
- Performed in young infants and those in status epilepticus
- Select studies in other children reflecting history and physical exam:
- Patients on anticonvulsant therapy:
- Febrile seizure:
- Lab studies to evaluate for a serious underlying bacterial infection if suspected
Imaging
- Head CT:
- Focal seizure
- New focal neurologic abnormality
- Suspected intracranial hemorrhage or mass lesion
- New-onset status epilepticus without identifiable cause
- Not routinely indicated for 1st afebrile seizure
- Lumbar puncture:
- Suspicion of meningitis or encephalitis
- CT 1st if suspect increased intracranial pressure
- MRI:
- Rarely urgently indicated for seizures
- EEG:
- Generally indicated in children with an afebrile seizure as a predictor of risk of recurrence and to classify the seizure type/epilepsy syndrome
- Postictal slowing seen within 24–48 hr of a seizure and may be transient; delay EEG if possible
- Rarely helpful in the acute setting
DIFFERENTIAL DIAGNOSIS
- Neonates:
- Infants and toddlers:
- Breath-holding spells
- Night terrors
- Children and adolescents:
[Outline]
PRE-HOSPITAL
Cautions:
- Many conditions may be mistaken for seizures (see "Differential Diagnosis," below)
- Immobilize cervical spine if trauma suspected
- Check fingerstick glucose or administer dextrose as appropriate
INITIAL STABILIZATION/THERAPY
- ABC support if actively seizing
- Airway:
- Oxygen/monitor pulse oximetry
- Nasopharyngeal airway preferred over oral airway
- Bag valve–mask support if hypoventilating or persistently hypoxic
- Intubation if seizures are refractory and bag valve–mask support is unsuccessful
- IV access:
- If hypoglycemic, give dextrose
- Maintain spine precautions if trauma suspected
ALERT
Airway and breathing must be stabilized concurrent with management of ongoing seizures if present
ALERT
Early treatment of long-lasting seizure is critical in reducing potential morbidity, including brain damage
ED TREATMENT/PROCEDURES
Status Epilepticus
- Benzodiazepine:
- When treating IV lorazepam is preferred due to its longer duration of action
- Valium is acceptable
- If IV access is not available:
- Phenytoin:
- If benzodiazepines fail
- For longer-term control
- Fosphenytoin easier to administer
- Phenobarbital:
- Use if benzodiazepines and phenytoin fail to break the seizure
- Risk of respiratory depression greatly increases if a benzodiazepine has also been given
- Alternative therapies in the event of refractory status epilepticus
- Consultation appropriate:
- Paraldehyde (per rectum)
- Barbiturate coma:
- Barbiturate (pentobarbital) coma requires intubation and EEG monitoring to be sure the seizure is suppressed
- Associated hypotension
- General anesthesia:
- A final resort
- Continuous EEG is needed to be sure the seizure is abolished
- Neonates:
- Phenobarbital is an acceptable 1st-line therapy
- Preferred maintenance drug
ALERT
Note: Aggregate response to 2nd- and 3rd-line agents is < 10%
MEDICATION
- D10: 5 mL/kg IV for neonates
- D25: 2 mL/kg IV for children
- Diazepam: 0.2 mg/kg IV (max. 10 mg); 0.2–0.5 mg/kg PR (max. 20 mg)
- Fosphenytoin: 20 mg/kg IV over 20 min
- Lorazepam: 0.1 mg/kg IV, IN (max. 5 mg)
- Midazolam: 0.05–0.1 mg/kg IV; 0.2 mg/kg buccal/IN/IM (max. 7.5 mg)
- Pentobarbital: 3–5 mg/kg IV over 1–2 hr; maintenance: 1–3 mg/kg/h IV; monitor for respiratory depression
- Phenobarbital: 15–20 mg/kg IV over 20 min; monitor for respiratory depression
- Phenytoin: 15–20 mg/kg IV slowly over 30–45 min
[Outline]
DISPOSITION
Admission Criteria
- ICU:
- Active status epilepticus, intubated, or persistent mental status changes
- Repetitive seizures in narrow time frame
- Inpatient unit:
- Status epilepticus resolved in the ED
- Underlying cause of seizure unresolved, uncontrolled, or poorly understood
- Intracranial hemorrhage
- Mass lesion
- Meningitis/encephalitis
- Drug
- Toxin ingestions
Discharge Criteria
- The child is alert with normal mental status and neurologic exam
- No evidence of an underlying cause requiring hospitalization
- Reliable parent or caregiver
- Home telephone
Issues for Referral
Unresponsive or repetitive seizures
FOLLOW-UP RECOMMENDATIONS
- Provide seizure precautions and aftercare instructions
- Follow-up with PCP or pediatric neurologist
[Outline]
- Abend NS, Huh JW, Helfaer MA, et al. Anticonvulsant medications in the pediatric emergency room and intensive care unit. Pediatr Emerg Care. 2008;24(10):705–718.
- Barata I. Pediatric seizures. Crit Decisions Emerg Med. 2005;19:1–10.
- Blumstein MD, Friedman MJ. Childhood seizures. Emerg Med Clin North Am. 2007;25:1061–1086.
- Lagae L. Clinical practice: The treatment of acute convulsive seizures in children. Eur J Pediatr. 2011;170:413–418.
- Sofou K, Kristjànsdóttir R, Papachatzakis NE, et al. Management of prolonged seizures and status epilepticus in childhood: A systematic review. J Child Neurol. 2009;24(8):918–926.
- Yoshikawa H. First-line therapy for theophylline-associated seizures. Acta Neurol Scand. 2007;115:57–61.
See Also (Topic, Algorithm, Electronic Media Element)
Seizures, Febrile