Rosen & Barkin's 5-Minute Emergency Medicine Consult (641 page)

• 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
  

• Bedside glucose test
  
• Performed in young infants and those in status epilepticus
  
• Select studies in other children reflecting history and physical exam:
  
  • Electrolytes
    
  • BUN
    
  • Creatinine
    
  • Glucose
    
  • Calcium
    
  • Magnesium
    
  • CBC
    
  • Toxicology screen
    
• Patients on anticonvulsant therapy:
  
  • Drug levels
    
• Febrile seizure:
  
  • Lab studies to evaluate for a serious underlying bacterial infection if suspected
    

• 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
    

• Neonates:
  
  • Apnea due to other causes
    
  • Jitters or tremors
    
  • Gastroesophageal reflux
    
• Infants and toddlers:
  
  • Breath-holding spells
    
  • Night terrors
    
• Children and adolescents:
  
  • Migraine headache
    
  • Syncope
    
  • Tics
    
  • Pseudoseizures
    
  • Hysteria
    

TREATMENT

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
  

• 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
  

• Benzodiazepine:
  
  • When treating IV lorazepam is preferred due to its longer duration of action
    
  • Valium is acceptable
    
  • If IV access is not available:
    
    • Buccal midazolam (most convenient)
      
    • Intranasal lorazepam
      
    • Per rectum diazepam
      
• 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
    

• D
  ₁₀
  : 5 mL/kg IV for neonates
  
• D
  ₂₅
  : 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
  

FOLLOW-UP

• 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
    

• 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
  

Unresponsive or repetitive seizures

• Provide seizure precautions and aftercare instructions
  
• Follow-up with PCP or pediatric neurologist
  

• Phenobarbital is the preferred treatment for theophylline-induced seizures, poor response to benzodiazepines and phenytoin
  
• Consider buccal or intranasal benzodiazepine if no IV access
  

• 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, Kristjánsdóttir 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

CODES

• 780.31 Febrile convulsions (simple), unspecified
  
• 780.33 Post traumatic seizures
  
• 780.39 Other convulsions
  

BASICS