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Department of Pediatrics : Academic Divisions : Emergency Medicine : Resident Manual : Seizures

Definitions
Partial seizures: focal seizures which are either simple (no loss of consciousness) or complex (consciousness impaired or tendency to generalize); usually associated with aura.

Generalized seizures: involving all or large parts of the cerebral cortex; include absence (petit-mal), tonic, clonic, tonic-clonic (grand-mal) , myoclonic, or atonic (drop attacks).

Status epilepticus (SE): a single seizure lasting for at least 30 minutes, or recurrent seizures lasting for more than 30 minutes without full recovery of consciousness during the interictal period. Febrile SE accounts for 25% of all SE in children.

Febrile seizure: brief, generalized seizure event in a child (3 mo- 6 yrs) with peak incidence at 18 mo. In the general population, 2-4% of children will have one febrile seizure in their lifetime.

Complex febrile seizure: seizure with fever complicated by at least one atypical factor such as focality on exam, > 1 seizure per illness, or a prolonged duration (>10-15 minutes).

Pseudoseizures: realistic movements mimicking seizures but frequently bizarre, with unusual postures, verbalizations, and uncharacteristic tonic or clonic movements. Typically occur in girls between 10 and 18 years of age.

Evaluation
First determine if you are actually observing a seizure. The differential includes syncope, breath-holding, movement disorders, hyperventilation syndrome, or pseudoseizures.

Children with seizures or SE will usually have one of three types of seizures:

  1. Febrile Seizures:
    Simple febrile seizures rarely require laboratory evaluation or treatment. The typical child with a febrile seizure will recover in ~1 hour without sequelae. If there is ANY concern for an infectious process (e.g. meningitis or encephalitis), a lumbar puncture should be performed. Many advocate LP's in infants less than 6 months with febrile seizure.

    The risk of recurrent febrile seizures is only 30-40%. Risk factors include: lower temperature at time of seizure, (+) family hx of febrile seizures, age < 18 months, and brief duration of illness prior to seizure

    Only 2-4% of children with febrile seizures will go on to develop epilepsy. There is almost no indication for anti-epileptic drug (AED) use in simple febrile seizures.
     
  2. New Onset Non-Febrile Seizure

    Etiologies include:
    Infectious- meningitis/encephalitis, abscess, shigellosis, parasite
    Idiopathic
    Metabolic- hypo/hypernatremia, hypoglycemia, hypocalcemia, inborn errors
    Drugs/toxins- a very long list!!
    Congenital structural abnormalities- neurofibromatosis, malformation, atrophy
    Anoxia
    Trauma- subdural hematoma, epidural hematoma, concussion, shaken baby syndrome
    Vascular- stroke (embolic/thrombotic), collagen vascular disease
    Tumor

    Laboratory tests should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline alertness. Laboratory evaluation may include electrolytes, glucose, calcium, magnesium, and phosphorus; urine drug screen; CBC.

    A lumbar puncture is of limited value in the initial evaluation of children with simple afebrile seizures, UNLESS there is concern about meningitis or encephalitis. Consider a CT scan/MRI if the exam or seizure is focal.

    An EEG is recommended as a part of the neurodiagnostic evaluation. It aids in predicting the risk of recurrence and helps classify the seizure type. It can be scheduled as an outpatient procedure.

    The risk of recurrence after a first unprovoked seizure is higher (>50%) for remote symptomatic cases (e.g. prior insults such as static encephalopathy, head trauma, intracranial bleed) or with Todd's paresis. Status epilepticus as a first seizure does NOT increase the seizure recurrence risk.
     
  3. Known Seizure Disorder
    These patients are usually on chronic anticonvulsants and have breakthrough seizures because the AED levels are low or because of an intercurrent infectious illness. Evaluate these patients thoroughly for a source of infection (otitis media, pneumonia, viral URI) and check their AED levels. If levels are low, consider a bolus of anticonvulsant medication. If in doubt, contact the patient's regular neurologist/pediatrician. Disposition again depends on the results of your evaluation, although admission is often not needed.

    Pseudoseizures (PS):
    The diagnosis should be made only after a thorough history and physical exam with ancillary EEG recording if needed. Pseudoseizures may occur in patients with a neurotic personality, a past history of epilepsy or occasionally with current epilepsy. Clues to help in recognizing a PS include no cyanosis, normal pupillary reaction, no loss of sphincter control, no Babinski, vocalization such as moaning or crying, and absence of tongue biting or other injuries during an attack. VideoEEG recording may be necessary for diagnosis.


AED Therapy

NAMEUSUAL DOSEADVERSE EFFECTSLEVELS (mcg/ml)
Carbamazepine (Tegretol)5-30 mg/kg/daplastic anemia, somnolence, dizziness4-14
Ethosuximide (Zarontin)20-30 mg/kg/dN & V
Phenobarbital3-8 mg/kg/dhyperactivity, sedation10-35
Phenytoin (Dilantin)5-10 mg/kg/dgingival hyperplasia, hirsutism, ataxia10-20
Valproic Acid (Depakene, Depakote)15-65 mg/kg/dN & V, hepatotoxiciy, bone marrow suppression, pancreatitis, tremors50-100


New AED's

NAMEUSUAL DOSEADVERSE EFFECTSLEVELS ##
Felbamate (Felbatol)40-100mg/kg/daplastic anemia, hepatotoxicity, anorexia, N & V, insomnia, somnolence
Gabapentin (Neurontin)30-90 mg/kg/dataxia, behavioral changes, dizziness, fatigue, wt. gain, somnolence
Lamotrigine (Lamictal)1-15 mg/kg/d **5 mg/kg/d if on VPAataxia, diplopia, dizziness, HA, N&V, Stevens-Johnson Syndrome, somnolence
Levetiracetam (Keppra)250-1000 mg BIDbehavioral changes, somnolence, fatigue, coordination problems
Topiramate (Topamax)3-7 mg/kg/dataxia, confusion, diplopia, fatique, HA, nystagmus, psychomotor slowing, parestheis, somnolence
Tiagabine (Gabitril)< 1mg/kg/ddizziness, HA, somnolence
Oxcarbazepine (Trileptal)8-50 mg/kg/dhyponatremia, psychomotor slowing, somnolence, fatigue, ataxia
Zonisamide (Zonegran)5-15 mg/kg/dSULFA drug allergies, renal stones, somnolence, aplastic anemia, decreased sweating

## Probably no role for drawing anticonvulant drug levels in the Peds ED



Management of Status Epilepticus (SE)

Time: 0-5 min.
Initial Actions:

  • Diagnose SE
  • Open airway, jaw thrust, apply O2
  • Have suction, bag/mask available
  • Check vital signs and A,B,C's
  • Establish IV/IO and draw labs
  • [Dextrostix, Chem-10, CBC; +/- tox screens, blood cultures, AED levels]

Follow-up Actions:

  • Consider rapid sequence intubation
  • Put patient on monitor and pulse ox
  • Consider ABG

Time: 6-9 min.
Initial Actions:

  • If hypoglycemia present, give dextrose
  • Administer Lorazepam 0.1mg/kg IV, IO - (max dose = 4 mg at a time)
  • Administer Midazolam 0.2mg/kg IM, IN
  • Reassess A,B,C's

Follow-up Actions:

  • Alternative-Diazepam 0.2 mg/kg IV, IO; Diazepam 0.5-1.0 mg/kg PR (infuse in rectum with small syringe or catheter, elevate & squeeze buttocks)
  • Treat hyperthermia

Time: 10-20 min
Initial Actions:

  • Repeat Lorazepam 0.1 mg/kg every 5 minutes for TOTAL 3 doses (max = 4mg per dose)
  • Reassess A,B,C's

Follow-up Actions:

  • May repeat PR Diazepam after 5-10 min
  • May repeat IM Midazolam

Time: 21-60 min.
Initial Actions:

  • Phenytoin 15-20 mg/kg IV/IO (max = 50mg/min or 1 mg/kg/min; watch EKG; no dextrose in IV)
  • Repeat Phenytoin 5 mg/kg mini-bolus
  • Phenobarbital 20mg/kg IV/IO
  • Reassess A,B,C's: Plan on rapid sequence intubation & NG tube insertion
  • Alternative: Valproic Acid 15-20 mg/kg IV or 20 mg/kg PR

Follow-up Actions:

  • Alternative- Fosphenytoin 15-20 mg PE (phenytoin equivalent)/kg IV/IO or IM (max = 3 mg/kg/min)
  • Watch for respiratory depression; consider ABG to assess ventilation;
  • Check on labs; treat specific etiologies; treat hyperthermia
  • Send AED levels
  • Consider need for inotropes, vasopressors, fluid bolus, CT scan, continuous EEG

Time: > 60 min
Initial Actions:

  • Admit to PICU
  • Pyridoxine 100 mg/kg IV in infant with no etiology for SE
  • Consider Pentobarbital bolus and drip; Midazolam drip; propofol; isoflurane; lidocaine;

Follow-up Actions:

  • Consider need for inotropes, vasopressors, fluid bolus, CT scan, continuous EEG
  • Send AED levels


References:
Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures; a prospective cohort study. Arch Pediatr Adolesc Med. 1997; 151:371-378

Haafiz A, Kissoon N. Status epilepticus: current concepts. Ped Emerg Care 1999; 15: 119-129

Hanhan UA, Fiallos MR, Orlowski JP. Status epilepticus. Ped Clinic NA 2001;

Hirtz D, Ashwal S, Berg A et al. Practice parameter: evaluating a first nonfebrile seizure in children; report of the Quality Standards Subcommittee of the AAN, CNS, and AES. Neurology 2000; 55:

Painter MF, Scher MS, Stein AD et al. Phenobarbital compared with phenytoin for the treatment of neonatal seizures. N Engl J Med 199; 341: 485-489

Pellock JM. Managing pediatric epilepsy syundromes with new antiepileptic drugs. Pediatr 1999. 104: 1106-1116

Wolf AM, Ochoa JG, Conway EE. Seizure management in pediatric patients for the nineties. Ped Annals 1998; 27: 653-664

Yamamoto LG, Yim GK. The role of intravenous valproic acid in status epilepticus. Ped Emerg Care 2000; 16:296-298

For additional reading, refer to "Status epilepticus: Current concepts" by Allah Haafiz, MD and Niranjan Kissoon, MBBS, Pediatric Emergency Care Journal, Vol. 15, No. 2, 1999.


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