Pediatric Seizures

ED evaluation during or shortly after a seizure should begin with assessment of the patient's airway, breathing, and circulation. Ensure there are no foreign bodies in the mouth to prevent aspiration and reposition the airway as needed. Many patients may maintain a normal pulse oximeter reading despite inadequate ventilation, so assess for both oxygenation and ventilation by exam, capnography, and/or lab evaluation. Provide supplemental oxygen or advanced airway support as needed, and continuously monitor vital signs.

During the secondary and tertiary exam, consider obtaining a bedside glucose as a quick test to rule-out hypoglycemic seizure. Next, the semiology of the seizure should be carefully noted by the clinician.

Important characteristics to note include:

• Type of Seizure: Generalized (both cerebral hemispheres involved).
  • Tonic: Increased tone.
  • Clonic: Rhythmic Shaking.
  • Tonic-Clonic: Rhythmic shaking with increased tone.
  • Myoclonic: Sudden muscle contractions or spasms.
  • Atonic: Sudden loss of muscle tone ("drop attacks").
  • Absence: Brief episode of staring followed by quick return to baseline ("staring spells").
• Type of Seizure: Partial/focal/local (one cerebral hemisphere involved with motor, sensory, psychic, or autonomic symptoms).
  • Simple: Consciousness intact.
  • Complex: Consciousness impaired.
• Location: Does the seizure involve the entire body (generalized) or is it limited to one extremity/side (focal)? Did it start in one portion of the body then generalize? 
• Eyes: Are the pupils midline or deviated to the right/left? Note the pupil sizes as well.
• Duration: Note the total time that the patient was convulsing, as well as the time it took from the end of the convulsion to return to the patient's baseline neurologic function (post-ictal period).

If the seizure has lasted longer than five minutes, it is appropriate to give medication to stop the seizure. Of note, treatment of neonatal (<29 days) seizures is complex and controversial, and will not be covered in detail in this chapter. First line therapy for patients outside of the neonatal period is administration of a benzodiazepine. Treatment will be discussed in further detail later in the chapter.

Most patients will present to the ED after the seizure activity has already stopped. It is important to ask the family or caregivers questions about the seizure characteristics. Prior medical history can also be very helpful. Important questions to ask include:

• History of prior seizures and respective medications.
• Recent fever or other sick symptoms.
• Presence of preceding aura or headache.
• Recent head trauma.
• Ingestion of drugs or toxins.
• History of other neurologic disorders or chronic medical problems.
• Immunization status.
• Family history of seizures.

Febrile Seizures account for the majority of seizures in pediatric patients and occur in 2-5% of all children. They occur between the ages of six months and six years, with peak incidence between 12-18 months. Simple febrile seizures are generalized tonic-clonic in nature, last less than ten minutes, and do not recur in a 24-hour period. Complex febrile seizures are focal, are prolonged longer than ten minutes, and recur within a 24-hour period.

While approximately one-third of children with febrile seizures will have a recurrence before age six, simple febrile seizures only minimally increase a child's risk of developing epilepsy in the future. Children with simple febrile seizures have a 1-2% risk of developing epilepsy and those with complex febrile seizures have a 5-10% risk. The use of antipyretics is generally not thought to decrease the risk of recurrence of febrile seizures, although there is one recent, but limited, study suggesting that the use of acetaminophen may decrease risk during the same fever episode.

Epilepsy is a group of central nervous system disorders in which nerve cell conduction becomes disrupted, causing seizures. There are many different types of epilepsy that require detailed diagnostic testing with a pediatric neurologist. As these evaluations are not typically part of the ED evaluation, they will not be discussed here.

Some patients will present to the ED with status epilepticus. In the past, status epilepticus was defined as convulsive seizures that last greater than 30 minutes or two or more seizures that occur in a 30-minute period. More recently, however, this definition has been revised, as we learn that seizures are more likely to respond to pharmacologic therapy if acted upon early. Currently, any prolonged seizure lasting greater than five minutes or recurrent seizures lasting longer than five minutes without interval return to baseline consciousness is considered status epilepticus, requiring emergent evaluation and management.

A careful physical exam is critical in evaluating a patient after a seizure. The examiner should do a complete neurologic exam looking for subtle hemiparesis, changes in strength, clonus, and increased/decreased tone. As infectious causes are often in the differential, patients should be evaluated for meningismus or presence of a concerning rash. The examiner should also note any tongue biting and loss of continence to urine or stool that occurred with the seizure.

The majority of seizures in otherwise healthy children between six months and six years of age are febrile seizures. If the history is consistent with a concurrent febrile illness, the patient has returned to baseline, and the neurologic exam is non-focal, no specific testing is required. This remains true regardless of whether the febrile seizure was simple or complex. Testing should then be focused on determining the cause of the fever, if indicated. Infants under the age of six months presenting with seizure should not be considered a febrile seizure and warrant further evaluation based on their presentation.

If the patient exhibited a generalized seizure in the absence of fever, an electroencephalogram (EEG) is likely indicated. For patients who have returned to baseline, this is typically non-emergent and may be done as an outpatient. If there are focal neurologic findings on exam, emergent head imaging with a computed tomography (CT) scan or magnetic resonance imaging (MRI) and neurology consultation are recommended. Other studies such as toxicology screening, laboratory tests, and lumbar puncture should be done only when clinically indicated as they are low-yield when used as screening tests.

The first step in treatment is ensuring a safe environment for the patient by removing items from the patient’s mouth and lowering the patient to the ground or bed. Most seizures are self-limited and do not require pharmacologic therapy. If the seizure persists longer than five minutes, a benzodiazepine should be administered as a first-line agent. Lorazepam (Ativan) is the preferred agent given its long half-life. Other agents may be used in the event that the patient does not have intravenous access or if lorazepam is not immediately available. Diazepam offers the benefits of being stable at room temperature for long periods of time (making it a preferred agent for out-of-hospital use) and is also available in a rectal gel formulation (Diastat) for home use. Midazolam (Versed) may be administered via intramuscular, intranasal, buccal, or rectal routes, but is not a preferred intravenous agent given its short half-life. All of these medications are available in oral formulations, but oral medications should never be given to an actively seizing or post-ictal patient.

If a seizure has not stopped after at least two appropriately-dosed trials of a benzodiazepine, a second-line agent should be used. A recent randomized trial of fosphenytoin (Cerebyx), levetiracetam (Keppra), and valproic acid (Depakote) found similar efficacy and safety profiles across all three agents, and any of these are acceptable accounting for patient, availability, and familiarity factors.

Neonatal (<29 days of age) seizures present a more complex pathology without clear guidelines in first-line antiepileptic recommendations. While a benzodiazepine may be appropriate in some situations (i.e. other antiepileptic medications are not immediately available), due to the risk of respiratory depression, phenobarbital or phenytoin are more commonly recommended. However, the identification and treatment of the underlying seizure etiology (e.g. electrolyte, infectious, traumatic, genetic causes) must be prioritized. Otherwise, neurology consultation should provide guidance for antiepileptic and evaluation practices.

Typical Dosing of Antiepileptic Medications

• The evaluation of any seizing patient should begin with the ABCs (airway, breathing, circulation).
• Careful observation of seizure semiology is helpful in determining workup and management of seizure in the ED.
• Febrile seizures are common (2-5% of children), benign, and usually self-limited.
• Status epilepticus is defined as prolonged seizure lasting greater than five minutes, or multiple seizures without return of consciousness in between events lasting greater than five minutes.
• Neonatal (<29 day old) seizures often have an underlying treatable etiology, with antiepileptic management dictated by local expertise.
• Seizures lasting longer than five minutes should be treated with a benzodiazepine (Lorazepam is the preferred IV agent). Fosphenytoin (Cerebyx), levetiracetam (Keppra), and valproic acid (Depakote) have been found to be equally safe and efficacious second-line agents.

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