- Status epilepticus and neonatal seizures require immediate evaluation and treatment in the ED, while other seizures in otherwise healthy children may not require a full evaluation. - Seizures are classified as focal or generalized, and status epilepticus is defined as a prolonged seizure or recurrent seizures lasting over 5 minutes without consciousness returning. - Evaluation of seizures includes bedside glucose, electrolytes, imaging if indicated by history, and EEG for refractory or prolonged seizures. Treatment involves benzodiazepines for active seizures, followed by antiepileptic drugs if needed.

1. SEIZURE IN INFANT AND
CHILDREN
BY AGH PAKNIYAT

2. • status epilepticus and neonatal seizures need emergent evaluation and treatment , while other seizure
in children that are well may not needed completely evaluation in ED.

3. TYPES OF SEIZURE
• Focal
• Generalized ; convulsive and non convulsive ;
 absence seizures (brief episode of staring without a postictal state)
 atonic seizures (sudden loss of muscle tone with a sudden “drop” to the floor)
 myoclonic seizures.
 Partial seizures ; Simple or Complex
 Status Epilepticus : any “prolonged” seizure, or recurrent seizures lasting >5 minutes without
return to full consciousness, is considered status epilepticus
 Nonconvulsive status epilepticus may present as a prolonged postictal state and must be
considered in any patient with altered mental status,

6. LAB TEST
• bedside glucose on all pt.
• Additional laboratory evaluation : directed by the history and is not routinely indicated for febrile
seizures or first-time afebrile seizures that are nonfocal in a child with a normal examination.
• electrolytes (including calcium)
• serum antiepileptic medication levels, toxicologic testing
• spinal fluid for evaluation of possible central nervous system infection
• Urine culture and analysis : febrile seizures in the child with fever and no identifiable source.
• Electrocardiogram
• Emergent electroencephalogram monitoring : refractory status epilepticus

7. IMAGING
• Routine neuroimaging is rarely indicated or helpful : trauma or in the setting
of focal deficits.
• Todd’s paralysis : temporary ; focal deficit of unknown etiology ; last up to 36
hours after a seizure. unilateral and lasts on average 15 hours; it can be
bilateral and involve a patient’s speech or vision. Immediate Ct for R/o of
Stroke or ICH.
• Most first-time seizures in the well-appearing child with a normal examination
are best evaluated with outpatient MRI, which avoids ionizing radiation and
provides better anatomic detail.

9. TREATMENT : PREHOSPITAL
• BNZ : IV , IN , Buccal , Rectal or intraosseous route
• Diazepam Rectal ; Short half time
• Midazolam is rescue drug , use IN
• Lorazepam not useful in prehospital or at home , need IV line,
There is new evidence that intranasal lorazepam using a MAD®
may be as effective as IV lorazepam in the treatment of status
epilepticus.

10. TREATMENT OF STATUS EPILEPTICUS: ED
• Administer oxygen by facemask
• institute continuous pulse oximetry
• cardiac monitoring
• IV or intraosseus (IO) access
• administer medication early via alternate routes (intranasal, IM, PR, buccal) if
there is IV delayed.
• Obtain bedside glucose testing and electrolyte levels when available.
• The decision to intubate is clinical :Intubate for apnea and persistent hypoxia.
• Blood gas concentrations are not needed to guide the decision to intubate
• arrange continuous electroencephalogram monitoring for intubated
patients with status epilepticus.

12. CONTINUE …
• First line :
• BNZ :
lorazepam is preferred .
if two doses of benzodiazepines not effective, additional doses are unlikely to be successful.
• fosphenytoin, levetiracetam, phenobarbital, or valproic acid are preferred second-line
treatment choices.
• choose two of the four medications for refractory status epilepticus and then move on to a
fourth-line treatment option if a seizure persists.

14. • Second and third line :
• Fosphenytoin
is preferred as second-line treatment over phenobarbital except in
neonates.
• it has a different mechanism of action from benzodiazepines and
phenobarbital, which both bind gamma-aminobutyric-acid
receptors.
• Monitor serum levels in patients with renal or hepatic dysfunction.

15. • Levetiracetam
eliminated solely via renal excretion and has no hepatic
metabolism
• it is commonly used for maintenance therapy for multiple
seizure types.

16. • Phenobarbital
used in neonates who are often maintained on daily
phenobarbital for subsequent seizure control.
• Side effects include sedation and cardiorespiratory
depression, which may be amplified by benzodiazepines

17. • Valproic acid
treatment of children already taking this medication who are suspected of
having subtherapeutic levels.
• twenty to 40 milligrams/kg of IV valproic acid effectively terminates seizure
activity with few side effects or less sedation.
• caution in children at risk for metabolic disease, because in rare cases it may
cause hepatic failure
• has rarely been associated with thrombocytopenia

19. • Fourth-Line Treatment:
• Propofol: effectively treat refractory status epilepticus better than
pentobarbital.
• Slowly infused : bradycardia, apnea, and hypotension.
f propofol infusion syndrome: receiving sustained propofol
administration (>24 hours) :
• Metabolic acidosis, rhabdomyolysis, renal failure, and cardiac
failure

20. • pentobarbital coma:
• respiratory depression, hypotension, and decreased
cardiac contractility, and most patients require
intubation and inotropic support

21. • Midazolam infusion : less adverse effect but has a
higher rate of seizure recurrence

24. • hypoglycemia : rapid infusion of 2 mL/kg of 25% dextrose in water or 5
mL/kg of 10% dextrose in water.
• hyponatremia : 3% NaCl 4 to 6 mL/kg over 20 minutes, or begin an
infusion of 20 mL/kg of 0.9% NaCl if 3% NaCl is not immediately
available. The sodium level should be rechecked after the bolus to
determine whether a second bolus is necessary
• Hypocalcemia: Calcium gluconate 0.3 mL/kg over 5 to 10 minutes is
preferred over calcium chloride when infusing through a small
peripheral IV, as calcium chloride can cause local irritation.
• hypomagnesemia (serum magnesium <1.5 mEq/L) : magnesium sulfate
50 milligrams/kg IV infused over 20 minutes.

25. • Discharge :
• Infants >6 months of age with febrile seizures
• children with single seizures lasting <15 minutes who return to baseline
mental status
and have no focal neurologic deficits or secondary cause of seizure
requiring.
• Children with prolonged seizures and those with refractory seizures
requiring ED treatment who stop seizing should be observed for 24
hours and monitored for recurrence or side effects from medication.

26. SIMPLE FEBRILE SEIZURES
• no blood studies, neuroimaging, or electroencephalogram is
necessary for most simple febrile seizures and the evaluation should
focus on identifying the source of fever.
• Consider lumbar puncture : infants 6 to 12 months of age who are
unimmunized for Haemophilus influenza type B or streptococcus
pneumonia and those taking antibiotics, which can mask the signs and
symptoms of meningitis
• Having a febrile seizure does not mean that a child will develop
epilepsy; The overall risk of recurrence after a single afebrile seizure is
about 40%.

27. FACTORS THAT INCREASE RISK OF RECURRENT SEIZURE:
• family history of seizures,
• multiple febrile seizures,
• first febrile seizure before 12 months of age.
• developmental delay
• focal seizures
• Todd’s paralysis
• focal neurologic findings on examination
• abnormal findings on electroencephalogram, CT, or MRI.

28. COMPLEX FEBRILE SEIZURES
• seizures with fever that last >15 minutes, that recur within a 24-hour period,
are focal, or occur in children <6 months or >5 years of age without any signs
of serious infection.
• Routine blood tests and imaging are not indicated, even in the setting of
complex febrile seizure, if the child returns to baseline in the ED.
• Children with a prolonged seizure ;fever ; appear ill : undergo evaluation to
rule out serious bacterial infection in the blood and cerebrospinal fluid , but
not delay for AB.
• Although antipyretics are indicated in children with fever, there is no evidence
that antipyretics can prevent subsequent febrile seizures

29. • If there is evidence that the child had vomiting or diarrhea, is
dehydrated, or fails to return to baseline, laboratory tests are
recommended.
• An electroencephalogram should be performed, the timing is
unclear: an electroencephalogram within 24 hours of the seizure is
most likely to show abnormalities; an electroencephalogram
within 24 to 48 hours may also show some transient postictal
slowing.

30. INDICATIONS FOR EMERGENT HEAD CT :
• Condition predisposing them to intracranial abnormalities,
• with focal seizures
• children younger than 33 months of age with new-onset
seizures.

31. • Outpatient MRI should be considered in any child
with any of the following:
• significant cognitive or motor impairment
• abnormal findings on neurologic examination
• abnormal electroencephalogram findings
• partial seizure
• infants <1 year of age.

32. NEONATE SEIZURE
• Apparent life-threatening events ; pallor or cyanosis and a change in muscle
tone
• Regarneonates with witnessed seizures require extensive evaluation.
• Obtain cultures of blood, urine, and cerebrospinal fluid and test for herpes
simplex virus
and begin empiric parenteral antibiotics and acyclovir.
• Neonates with seizures are more likely to have electrolyte abnormalities than
older children, and electrolytes including calcium and glucose should be
measured
• Consider head CT for concerns of nonaccidental trauma, intracranial
hemorrhage, infarction or mass (even without external signs of injury).
• Finally, if inborn errors of metabolism are suspected, obtain serum levels of
lactate and ammonia, as well as serum amino acids and urine organic acids

33. • Treat the actively seizing neonate with
benzodiazepines as with older children;
consider phenobarbital for second-line
therapy.

34. SEIZURE IN EPILEPTIC PATIENTS
• Subtherapeutic drug levels may result when a child outgrows a
previously prescribed dose, vomits medications due to an intercurrent
illness, starts a new medication (due to changes in drug
pharmacokinetics from drug interactions), or does not adhere to the
original drug regimen.
• Children with epilepsy may have a lower seizure threshold with febrile
illness, even with therapeutic anticonvulsant levels, and the ED
evaluation in these situations may be limited to determining the source
of fever

35. SEIZURES IN CHILDREN WITH
VENTRICULOPERITONEAL SHUNTS
• underlying epilepsy, shunt malfunction, and central nervous system
infection.
• radiographic ventriculoperitoneal shunt series
• head CT or “quick brain MRI” to evaluate for increased ventricular size.
• CNS infection : pediatric neurosurgeon should be consulted and the
shunt tapped for cerebrospinal fluid analysis and culture.
• Consider prior shunt infections

36. SEIZURES IN TRAUMA
• “Impact seizures” (seizures that occur within minutes of head trauma)
• seizures that occur in a more delayed fashion, however, are more
indicative of severe injuries.
• Children with identified intracranial injury and a witnessed seizure
should be treated with a loading dose of antiepileptic medication,
typically fosphenytoin 20 milligrams/kg IV, to prevent short-term
recurrence that can worsen traumatic brain injury and increase
intracranial pressure;
• benzodiazepines remain first-line treatment for active seizures in the
setting of trauma.

37. • Maintain a high index of suspicion for trauma in the setting of afebrile seizures in infants.