Author:
John P.Santamaria
StefaniAshby
Description
Sudden, abnormal discharges of neurons resulting in a change in behavior or function
Etiology
- Febrile seizures
- Infection
- Idiopathic
- Trauma
- Toxicologic:
- Ingestion
- Drug action
- Drug withdrawal
- Metabolic:
- Hypoglycemia
- Hypocalcemia
- Hypo/hypernatremia
- Inborn errors of metabolism
- Perinatal hypoxia
- Intracranial hemorrhage
- CNS structural anomaly or malformation
- Degenerative disease
- Psychogenic
- Ischemia
- Mass lesion
Signs and Symptoms
Neonates
- Subtle abnormal repetitive motor activity:
- Facial movements
- Eye deviations
- Eyelid fluttering
- Lip smacking/sucking
- Spasms of neck, trunk, or extremities
- 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:
- Defined as >30 min of continuous seizure activity. Treatment should be started when seizure has lasted >5 min without recovery in between
- Generalized is most common
- Sustained partial seizures
- Absence of 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
Diagnostic Tests & Interpretation
Lab
- Bedside glucose test
- Perform expand ed lab workup in young infants, those in status epilepticus, and others as history and physical warrant
- Electrolytes
- BUN
- Creatinine
- Glucose
- Calcium
- Magnesium
- CBC
- Toxicology screen
- Blood gas
- Blood culture
- Patients on anticonvulsant therapy:
- Seizure with fever:
- Lab studies to evaluate for a serious underlying bacterial infection if suspected
- CSF studies:
- Perform if suspicion of meningitis or encephalitis
- CT first if increased intracranial pressure is 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 first time seizure
- MRI:
- Rarely urgently indicated for seizures
- EEG:
- Rarely helpful in the acute setting
- 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
Differential Diagnosis
- Neonates:
- Apnea due to other causes
- Sleep myoclonus
- Jitters or tremors
- Gastroesophageal reflux
- Infants and toddlers:
- Breath-holding spells
- Night terrors
- Children and adolescents:
- Migraine headache
- Syncope
- Tics
- Pseudoseizures
- Conversion disorder
Prehospital
Cautions:
- Many conditions may be mistaken for seizures (see Differential Diagnosis, below)
- Protect the airway
- Oxygen
- Support breathing as needed
- Immobilize cervical spine if trauma suspected
- Check fingerstick glucose and administer dextrose as appropriate
Initial Stabilization/Therapy
- ABC
- Airway:
- Oxygen/monitor pulse oximetry
- Nasopharyngeal airway preferred over oral airway if needed
- Bag-valve-mask support if hypoventilating or persistently hypoxic
- Consider intubation if seizures are refractory or if bag-valve-mask support is unsuccessful
- Roll patient onto side, and /or suction secretions, to avoid aspiration
- 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
- Immediately address any metabolic abnormalities
- Treat any suspected/proven overdose
- Stepwise approach to pharmacologic therapy
- Benzodiazepine:
- IV lorazepam is first-line due to its longer duration of action
- IV diazepam is also acceptable
- If IV access is not available:
- Rectal diazepam
- Intranasal lorazepam or midazolam
- Buccal or IM midazolam (most convenient)
- Give second dose of benzo if seizure does not stop
- Levetiracetam
- Fosphenytoin:
- Phenobarbital:
- Continuous infusion
- Neonates:
- Phenobarbital is first-line therapy
- Fosphenytoin is also acceptable
ALERT |
| Note: Aggregate response to second- and third-line agents is <10%. Prolonged seizure activity can permanently damage neurons. The longer a seizure lasts, the less likely it is to stop spontaneously |
Medication
- D10: 5 mL/kg IV for neonates
- D25: 2 mL/kg IV for children
- Diazepam: 0.2 mg/kg IV or IO (max 8 mg); 0.5 mg/kg PR (max 20 mg)
- Fosphenytoin: 20 mg/kg IV over 20 min
- Levetiracetam: 20-60 mg/kg IV (max 2.5 g) over 15 min
- Lorazepam: 0.1 mg/kg IV, IO, IN (max 4 mg)
- Midazolam: 0.15 mg/kg IV; 0.2 mg/kg IM/buccal (max 10 mg); 0.3 mg/kg IN (max 10 mg)
- Pentobarbital: 10 mg/kg IV over 30-60 min; maintenance: 1-3 mg/kg/hr IV; monitor for respiratory depression
- Phenobarbital: 20 mg/kg IV/IO (max 1 g) over 15-30 min; anticipate respiratory depression
- Phenytoin: 20 mg/kg IV over 30-45 min
- Valproic Acid: 20-40 mg/kg over 10-15 min
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
Issues for Referral
Unresponsive or repetitive seizures
Follow-up Recommendations
- Provide seizure precautions and aftercare instructions
- Follow-up with PCP or pediatric neurologist
- AbendNS, HuhJW, HelfaerMA, et al. Anticonvulsant medications in the pediatric emergency room and intensive care unit . Pediatr Emerg Care. 2008;24(10):705-718.
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- BlumsteinMD, FriedmanMJ. Childhood seizures . Emerg Med Clin North Am. 2007;25:1061-1086.
- BrophyGM, BellR, ClaassenJ, et al. Guidelines for the evaluation and management of status epilepticus . Neurocrit Care. 2012;17(1):3-23.
- GlauserT, ShinnarS, GlossD, et al. Evidence-based guideline: Treatment of convulsive status epilepticus in children and adults: Report of the guideline committee of the American epilepsy association . Epilepsy Curr. 2016;16(1):48-61.
- LagaeL. Clinical practice: The treatment of acute convulsive seizures in children . Eur J Pediatr. 2011;170:413-418.
- SofouK, KristjánsdóttirR, PapachatzakisNE, et al. Management of prolonged seizures and status epilepticus in childhood: A systematic review . J Child Neurol. 2009;24(8):918-926.
- YoshikawaH. First-line therapy for theophylline-associated seizures . Acta Neurol Scand . 2007;115:57-61.
See Also (Topic, Algorithm, Electronic Media Element)
Seizures, Febrile