Pediatric Seizure

Question 1

How is the pediatric brain different from adult in regard to seizures?

Answer 1

Peds more prone to seizure, but also more likely to improve over time and possibly grow out of seizures

Question 2

What are the critical first steps in managing an ongoing pediatric seizure?

Answer 2

Patent airway
Give O2 to all seizing pts
Assist ventilation if needed
Check for and treat hypoglycemia
Give benzos

Question 3

What is the dosing for dextrose if needed to treat hypoglycemia in kids?

Answer 3

Infants: 4–5mL/Kg of 10% dextrose
Children: 2mL/Kg of 25% dextrose
IV/IO

Question 4

What are the first-line treatments and doses for pediatric seizure?

Answer 4

Lorazepam 0.1 mg/kg or,
Midazolam 0.1–0.2mg/kg IV/IO

If no access, give 0.2mg/kg IN versed (max 10mg)

Repeat dosing in 5 minutes if no response and prepare to support blood pressure and breathing from repeat dosing

Question 5

What are the second-line treatments and doses for pediatric seizure?

Answer 5

Given when 2 doses of benzos have been unsuccessful:
Infants: phenobarbitol 20mg/kg IV/IO (max 800mg)
Children: fosphenytoin 20PE/kg IV/IO over 20 minutes

Question 6

What are third-line treatments for refractory status epilepticus in kids?

Answer 6

Valproic acid 20mg/kg IV/IO or

Levetiracetam 20–30mg/kg IV/IO

Question 7

What are fourth-line treatments and doses for pediatric seizure?

Answer 7

Continuous infusions in the ICU:

Propofol or midazolam

Question 8

In addition to the primary survey and the drugs to break the seizure, what else needs to be addressed and how?

Answer 8

Replete electrolytes
Hyponatremia: <120mEq/L, 3% NaCl 4–6mL/kg
Hypocalcemia: <7 mg/dL, 0.3mL/kg of 10% calcium gluconate over 10 minutes
Hypomag: <1.5 mEq/L, 50mg/kg mag sulfate over 20 minutes

Question 9

Which kids with a seizure can be sent home?

Answer 9

Brief seizure that resolves on its own without full recovery and no focal neuro deficits

Question 10

Which kids with seizure are admitted?

Answer 10

Status Epilepticus: even if terminated in the ED should still be admitted
All infants with true seizures
ICU for any refractory cases, or seizures from trauma, CNS infection, or serious metabolic or electrolyte abnormalities

Question 11

What is the normal age for a febrile seizure?

Answer 11

6 months–6 years

Question 12

What constitutes a complex febrile seizure?

Answer 12

lasting more than 15 minutes
Focal, not generalized seizure
Recurrent seizures

Question 13

When do febrile seizures require testing and treatment?

Answer 13

Febrile status epilepticus is treated with standard seizure aborting agents and neuroimaging, CSF analysis and culture, and consideration of covering with antibiotics and acyclovir
Consider routine evaluation for the source of the fever

Question 14

When is neuroimaging indicated in a first-time seizure?

Answer 14

Only if there are focal neuro deficits on exam

Question 15

Which seizure patients require neuroimaging, lab work, and other evaluation?

Answer 15

Posttraumatic: consider head CT
Febrile status: Head CT and LP
Non-febrile status, focal seizure, or focal neuro deficit: neuroimaging, CMP, tox screens, ECG

Infants: Glucose, CMP, calcium, mg, ammonia, lactate, UA, CSF

Question 16

How do neonatal seizures differ from adult?

Answer 16

More likely to be subtle and focal than generalized

Question 17

How should a neonatal seizure be worked up?

Answer 17

Should have a full septic workup and be placed on antibiotics and antivirals until source identified.
Also worked up for trauma.

Question 18

What is first-line treatment for neonatal seizure?

Answer 18

Phenobarbitol