Seizures:Nuts and Bolts

National Pediatric Nighttime CurriculumWritten by Anna Lin, MDLucile Packard Children’s Hospital

Learning Objectives

Understand the importance of initial assessment of patients who have seizures

Be able to initiate treatment for patients who have seizures

Know alternatives to first line treatments for status epilepticus

Case #1

14-month-old developmentally normal boy who presents with generalized tonic-clonic seizures associated with fever.How would you initiate management?What other information would be useful to

you as you are starting to intervene?What type of work-up does this patient

need?

Case # 2

12-year-old boy with obstructive hydrocephalus and VP shunt who presents with generalized tonic-clonic seizures for the past 15 minutes.How would you initiate management?What other information would be useful to you

as you are starting to intervene?What type of work-up does this patient need?

Types of Seizure

Partial SeizuresSimple vs. ComplexDifferent types (motor, sensory, autonomic,

“psychic”) Generalized Seizures

Convulsive vs. NonconvulsiveSecondarily generalized vs. Secondary

Status Epilepticus

A patient is in status epilepticus if seizure activity has lasted > 30 minutes or there are multiple seizure episodes with failure to regain consciousness between episodes

This is an arbitrary definition

Management of Seizures

Initial assessmentAirwayBreathingCirculation

Call for helpHospitalistNeuroPICU/RRT

Ask for more history How long has the

patient been seizing? New-onset vs. known

seizure disorder Baseline seizure

frequency, is this typical or not?

Events leading up to this episode

Meds/triggers History of status

Management of Seizures Consider rapid work-up for underlying

etiologiesCNS infectionAcute HIEMetabolic diseaseElectrolyte imbalanceTBIDrugs, intoxications, poisoningsCerebrovascular event

Benzodiazepines Lorazepam (Ativan)

0.05-0.1 mg/kg IV q10-15 min, max dose 4 mg Less respiratory depression than diazepam, longer

duration of action, slower onset (2 min) Midazolam (Versed)

0.15 mg/kg IV then continuous infusion of 1 mcg/kg/min

Other formulations available: IM, buccal, intranasal, oral, and rectal

Short half life, faster onset (1 min)

Benzodiazepines (2) Diazepam (Valium)

0.05-0.3 mg/kg IV q15-30 min, max dose 10 mg

Quick onset (10-20 sec), rectal formulation, higher risk of respiratory depression

Not considered first lineLower efficacy Increased respiratory depression

Fosphenytoin/Phenytoin

Fosphenytoin (Cerebyx) 15-20 mg PE/kg IV/IM, may infuse 3 mg/kg/min (max 150

mg/min), max dose 1500 mg PE/24 hours Prodrug of phenytoin which has fewer side effects Can cause cardiac arrhythmias Avoid for status with myoclonic seizures or absence seizures Consider alternatives in seizures associated with illicit drug use

Phenytoin (Dilantin) Not used first line as there are many side effects

Cardiac arrhythmias/hypotension associated with propylene glycol used to dissolve phenytoin

Local pain, venous thrombosis and purple glove syndrome skin necrosis, limb ischemia amputation

Barbiturates Phenobarbital (Luminal)

15-20 mg/kg IV/IM, may repeat 5 mg/kg IV q15-30 min, max dose 40 mg/kg

Prolonged sedation, respiratory depression, hypotension Generally used after failure of benzodiazepines and

fosphenytoin Pentobarbital (Nembutal)

12 mg/kg IV followed by 5 mg/kg/hr infusion Titrate to EEG inactivity

Used for refractory status epilepticus

Other agents Propofol (Diprivan)

Rapid onset, short duration of action Mechanism of action is unclear Hypotension, apnea and bradycardia are common

Intubation and ventilation are required for the use of this medication

Prolonged use can result in hypertriglyceridemia and pulmonary edema

Associated with fatal acidosis and rhabdomyolysis

Other agents (2)

AEDs with some data to suggest use in refractory SEValproic acid (Depakote): not yet approved

for SE, some data to support its useTopiramate (Topamax): PO onlyLevetiracetam (Keppra): adult data only

References AAP Subcommittee on Febrile Seizures. Clinical

Practice Guideline—Neurodiagnostic Evaluation of the Child With a Simple Febrile Seizure. Pediatrics 2011, 127(2): 389-394

Singh RK, Gaillard WD. Status Epilepticus in Children. Current Neurology and Neuroscience Reports 2009, 9:137–144

Wilfong A. Overview of the classification, etiology, and clinical features of pediatric seizures and epilepsy. Up To Date, 2011.

Questions1. You are paged by the nurse to come to the bedside of a

patient with known seizure disorder who is actively seizing. On arrival to the bedside, you note that the patient is having tonic-clonic movements of all extremities, upward eye deviation, and frothing at the mouth. The next step in the assessment/management of this patient is to

A.Ask the nurse how long the patient has been seizing

B.Wait for your senior resident to come and assist you

C.Have the nurse give lorazepam through the IVD.Suction and secure the airwayE.Obtain a fingerstick blood glucose

QuestionsD.Suction and secure the airway

In all patients, the first assessment you make should be checking airway, breathing and circulation. Although you should call for help, you do not need to wait to start life-saving interventions. While lorazepam is an excellent anti-seizure medication, if your airway is not secure, you could risk putting this patient into respiratory failure. Asking for more information can be helpful in overall management, but is not the next best step. You can consider hypoglycemia as an underlying etiology, but this is also not the first step in your assessment.

Questions2.You are called to the Emergency Department to admit a 2-

year-old patient who had a 2 minute generalized tonic-clonic seizure associated with fever. The patient is well-appearing and at baseline neurological status 30 minutes after the event. His neurological examination is normal. What should you do?

A.Discharge the patient home after seizure education.

B.Admit the patient to the floor for overnight observation.

C.Recommend the Emergency Department obtain a head CT.

D.Obtain screening labs including a CBCD, chemistry panel and CRP.

E.Discharge the patient home with rectal diazepam.

QuestionsA.Discharge the patient home after seizure education.

This patient has had a simple febrile seizure. The general course of this disease process is benign. It needs no further work-up. Use of anti-epileptic medications is not indicated in simple febrile seizures. Admission is not necessary. Parents should be reassured about this incident and given education about recurrence risk and when to activate the emergency medical system (i.e. call 911).

Questions

3. All the following medications are used to treat status epilepticus EXCEPT

A.LorazepamB.FosphenytoinC.PhenobarbitalD.PropofolE.Levetiracetam

Questions

E.Levetiracetam

Levetiracetam (Keppra) is not routinely used to treat status epilepticus. Although there is some adult data to support its use, its use in pediatrics is not widespread. Other medications which are not routinely used in the treatment of status epilepticus in the pediatric population include valproic acid and topiramate. These medications may be used in refractory status epilepticus.

Questions

4. A 3-year-old boy with known seizure disorder is being admitted for increased seizure frequency. As you assess the patient, he develops generalized tonic-clonic seizures. He is maintaining his airway and oxygen saturation is 94% on RA. He is afebrile. He does not have IV access. What would you do next?

A.Administer buccal midazolam.B.Order an emergent head CT.C.Check electrolytes and glucose STAT.D.Obtain more history.E.Start a peripheral IV.

QuestionsD.Obtain more history. Since there is no vital sign instability, the patient does not require immediate treatment. This seizure may represent be typical for him. Important history to obtain includes frequency and type of seizures, medication history (what type of anti-epileptic therapy is the patient on and how often does he take it, has he missed any doses), any triggers for seizures/new exposures, previous history of status epilepticus and other recent events or symptoms.

Administration of buccal midazolam is not indicated if the seizure normally resolves within a few minutes. The patient may require further brain imaging. In a patient with known seizure disorder and no history of trauma or increased ICP, emergent head CT may expose the patient unnecessarily to high doses of radiation. MRI of the brain may the imaging modality of choice, but does not need to be performed emergently. Starting a peripheral IV and checking labs could be useful but are not the next steps in the evaluation of this patient.

Questions

5.Which of the following is TRUE about fosphenytoin/phenytoin?

A.Phenytoin is used first-line in status epilepticus.

B.Phenytoin can cause cardiac arrhythmia, but fosphenytoin does not.

C.The loading dose of fosphenytoin is 20 mg/kg PE IV or IM.

D.Fosphenytoin is best used for patients with myoclonic or absence seizures.

E.Phenytoin is a prodrug.

Questions

C.The loading dose of fosphenytoin is 20 mg/kg PE IV or IM.Fosphenytoin is ordered in mg PE (phenytoin equivalents). It is a prodrug which is converted into phenytoin. It can cause cardiac arrhythmias although less commonly than phenytoin. Phenytoin should be avoided in patients with myoclonic or absence status epilepticus. Phenytoin is not used first-line because of its cardiac arrhythmias and risk of venous thrombosis.