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Acute Care of Seizures of Cerebral Origin in Children

Essentials

  • A seizure with loss of consciousness is the most dangerous form of seizures in children and requires active emergency treatment. The majority of seizures, however, are of short duration (less than 4 minutes) and end spontaneously.
  • First aid medication is necessary if the seizure does not end spontaneously in a few minutes or if the seizure recurs before the child has recovered from the previous episode.
  • A prolonged epileptic seizure is a life-threatening emergency situation that requires immediate care, and a seizure that has lasted over 5 minutes is treated like a threating status epilepticus.
  • The essential elements in the treatment are maintenance of vital functions, termination of the seizure by first aid medication and etiological investigations to allow specific treatment (e.g. central nervous system infections).
  • All seizures in a child necessitate further investigations. The only exception is a sporadic short symmetric febrile seizure (fever over 38.5°C) in a child aged 6 months to 6 years with a history of febrile seizures in close relatives. Even for them, recurrence of the seizures during the same fever episode necessitates further investigation without delay. See also Febrile Seizures.
  • Mortality rate and the risk of disability increase if the seizure lasts for more than 30 minutes.
  • See also Epilepsy in Children for epilepsy in children.

First aid for seizures

Vital functions

  • Maintenance of vital functions: unobstructed airways (suction if necessary, oropharyngeal airway), lateral position, supplemental oxygen by mask
  • Measurement of blood pressure, pulse, and oxygen saturation (SpO2), immediate test for blood glucose

Lowering body temperature

  • Remove warm clothes, no physical cooling.
  • Give usual antipyretic drugs Febrile Seizures to reduce fever but only after anticonvulsive medication (see below) has been administered.

Placement of an intravenous line

  • Start an intravenous line if it can be done easily. Take a sample for the determination of blood glucose and electrolyte concentrations.
  • First medications are administered either buccally or rectally; see below.
  • For i.v. infusion, use physiological saline solution without glucose (unless the child is hypoglycaemic), or a Ringer-type solution.
  • Avoid excess fluids. A safe maintenance infusion rate is 0.1 ml/kg/min.

Medication Anticonvulsants for Status Epilepticus, Anticonvulsants for Neonates with Seizures

Benzodiazepines

Buccal dosage of midazolam.

Weight (age)Dose mg
5-10 kg (6-12 months)2.5 mg
11-20 kg (1-4 years)5 mg
21-40 kg (5-9 years)7.5 mg
>40 kg (> 10 years)10 mg
  • Single dose of rectal diazepam:
    • 5 mg for children weighing < 15 kg (aged 0-3 years) and 10 mg for children weighing > 15 kg (aged over 3 years).
    • A therapeutic serum concentration of diazepam is reached in about 5 minutes after the administration of the rectal solution. Suppositories are absorbed poorly - do not use them!
  • The buccal or rectal dose may be repeated once if needed, if no intravenous line has been established.
  • After an intravenous line has been placed the first aid medication is continued with an i.v. benzodiazepine (lorazepam, diazepam, or clonazepam).
    • Single intravenous dose of lorazepam and clonazepam is 0.1 mg/kg, maximum single dose being 4 mg.
      • The advantage of these drugs as compared to diazepam is a longer duration of action.
      • The IV solution may also be administered rectally with the same dosage.
    • Single intravenous dose of diazepam is 0.3 mg/kg, the maximum single dose being 10 mg.
      • The maximum cumulative dose (p.r. plus i.v.) is 1 mg/kg up to 20 mg, i.e. max. 20 mg.
  • Keep in mind that all benzodiazepines may cause respiratory depression. These drugs should always be given slowly within 2-3 minutes. Be always prepared to assist ventilation.

Laboratory tests and other procedures needed immediately

  • Determination and correction of blood glucose
    • If the child has hypoglycaemia (blood glucose below 4 mmol/l), infuse 10% glucose solution i.v. 2 ml/kg within 3-4 minutes. Monitor the blood glucose concentration.
  • Laboratory tests
    • CRP, sodium, potassium, blood glucose, haemoglobin, leukocytes, calcium, blood gases (Astrup). Do not wait for test results before transporting the patient to a hospital.
  • Hypocalcaemia
    • If there is a strong suspicion of hypocalcaemia, 10% calcium gluconate may be given i.v. (dose 0.5 ml/kg infused over 5 minutes) after the blood sample for determining plasma calcium has been taken. Always monitor ECG during calcium infusion.
  • Etiological investigations (e.g. a central nervous system infection, increased intracranial pressure) as soon as the child has been hospitalized

Treatment of prolonged seizures

  • If the seizure continues despite maximum benzodiazepine dose, lowering of temperature and treatment of hypoglycaemia and hypocalcaemia (if present), continue with the second-line intravenous medication.
  • For the second-line medication, levetiracetam or fosphenytoin, sometimes, especially in infancy, phenobarbitonemay be chosen.
    • Levetiracetam 100 mg/ml is diluted with 0.9% NaCl to a concentration of 40 mg/ml and administered as an intravenous infusion in 5-10 minutes. The loading dose is 40 mg/kg, and, as necessary, an additional dose of 20 mg/kg up to the maximum dose of 3 000 mg.
    • Fosphenytoin (Pro-Epanutin® ) is a prodrug of phenytoin. The solution contains 75 mg/ml of fosphenytoin, which is equivalent to 50 mg/ml of phenytoin (mg FE = phenytoin equivalents). All doses are given in phenytoin equivalents (mg FE).
      • The loading dose is 17-20 mg FE/kg, and the infusion rate is 2-3 mg FE/kg/min, max. 150 mg FE/min. For dosing and infusion rate, see table T2.
      • The drug may also be given as an intramuscular injection (no more than 10 ml in one injection site); a therapeutic concentration is reached in about 30 minutes from the administration.
      • The safety and efficacy of fosphenytoin has not been verified in children below 5 years of age.
      • ECG monitoring is necessary during i.v. infusion and for 30 minutes after its end (risk of arrhythmias).
    • The loading dose of phenobarbital is 15 mg/kg (maximum single dose 500 mg), given slowly i.v. with a speed of 30 mg/min (maximum speed 100 mg/min).

Pro-Epanutin ® loading doses

Weight (round upwards)Doseapproximately 15 mg FE/kgThe amount of Pro-Epanutin® (50 mg FE/ml)NaCl 0.9% or G5%Volume of dilutionInfusion rateInfusion time approximately
5 kg75 mg FE1.5 ml6 ml7.5 ml65 ml/h7.5 min
7.5 kg125 mg FE2.5 ml10 ml12.5 ml100 ml/h7.5 min
10 kg150 mg FE3 ml12 ml15 ml140 ml/h6.5 min
12.5 kg200 mg FE4 ml16 ml20 ml195 ml/h6 min
15 kg225 mg FE4.5 ml18 ml22.5 ml230 ml/h6 min
17.5 kg275 mg FE5.5 ml22 ml27.5 ml285 ml/h6 min
20 kg300 mg FE6 ml6 ml12 ml125 ml/h6 min
25 kg375 mg FE7.5 ml7.5 ml15 ml150 ml/h6 min
30 kg450 mg FE9 ml9 ml18 ml185 ml/h6 min
35 kg525 mg FE10.5 ml10.5 ml21 ml210 ml/h6 min
40 kg600 mg FE12 ml12 ml24 ml250 ml/h6 min
45 kg675 mg FE13.5 ml13.5 ml27 ml280 ml/h6 min
= 50 kg750 mg FE15 ml15 ml30 ml320 ml/h6 min
Max. dose750 mg FE Concentration< 20 kg 10 mg FE/ml,> 20 kg 25 mg FE/mlInfusion rate max.3 mg FE/kg/min
  • A seizure lasting longer than 30 minutes is associated with a risk of cerebral oedema. It is prevented with the following measures:
    • restriction of fluids (no more than 75% of the basic requirement)
    • do not give hypotonic solutions
    • give furosemide 1 mg/kg i.v.
    • raise the patient to an elevated position (30 degrees), with the head in mid-position.
  • Start arranging for transport to intensive care in a hospital simultaneously with the procedures described above.
    • As a seizure lasting longer than 1-2 hours may cause permanent brain damage, there is an urgent need for initiating intensive care (usually thiopental anaesthesia).

Transport to hospital

  • After a prolonged seizure or if the seizure is not stopped by the means described above, immediate transport under the supervision of a qualified person, preferably a physician, to the nearest hospital with preparedness for paediatric intensive care is always necessary.
    • The patient should be in lateral position during the transport to minimize the risk of aspiration. Vital functions should be monitored.
    • The means for suctioning airways, supplying extra oxygen, assisting respiration and administering additional drugs should be provided for the transport.
  • Urgent or, if needed, emergency referral for further investigations and follow-up at a hospital is necessary even after brief seizures if the child has not had seizures before.

Further investigations

  • After the first seizure, a paediatric neurologist or a paediatrician should always examine the child to establish aetiology and plan the prevention of further seizures. The only exception from this rule are the short typical febrile seizures Febrile Seizures. Instructions concerning first aid and medication are sufficient in that situation. Recurrence of febrile seizures may warrant further investigation.
  • Also absence seizures, attacks of blurred consciousness, seizures with only motor symptoms without disturbance of consciousness and seizures with myoclonic jerks require emergency investigations and treatment if they are prolonged or if the child has other symptoms suggesting e.g. an infection. The cause of short seizures in a child should be investigated without delay even if the child is in good general condition.
  • If the child is known to have epilepsy, he/she may be discharged home after a short seizure that was typical to the child, provided that he/she has fully recovered from the seizure. Otherwise the child should be referred to hospital for further investigations on emergency basis.
  • If the child is discharged home after a seizure, it is important to exclude any serious illness such as meningitis, encephalitis or a systemic disease.
    • This requires a sufficiently long follow-up after the seizure, clinical examination and, if needed, laboratory tests.
    • Bacterial meningitis may be a background factor in as many as 17% of cases of prolonged seizures occurring in association with fever in infants.

References

  • McIntyre J, Robertson S, Norris E, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 2005 Jul 16-22;366(9481):205-10 [PubMed]
  • Chin RF, Neville BG, Scott RC. Meningitis is a common cause of convulsive status epilepticus with fever. Arch Dis Child 2005 Jan;90(1):66-9 [PubMed]
  • Chamberlain JM, Kapur J, Shinnar S, et al. Efficacy of levetiracetam, fosphenytoin, and valproate for established status epilepticus by age group (ESETT): a double-blind, responsive-adaptive, randomised controlled trial. Lancet 2020;395(10231):1217-1224. [PubMed]
  • Dalziel SR, Borland ML, Furyk J, et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. Lancet 2019;393(10186):2135-2145. [PubMed]

Evidence Summaries ⬆