This document provides guidance on treating pediatric seizures in a pre-hospital setting. It reviews basic seizure first aid, classifications, status epilepticus as a medical emergency, management of febrile seizures which are usually benign, and evaluation after a first unprovoked seizure. The key steps are protecting the airway, giving rescue medications if a seizure lasts over 5 minutes, and transporting to the emergency department for evaluation of prolonged, complex, or repeated seizures.
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Pediatric Seizure Emergencies: ABCs and When to Worry
1.
2. objectives
5
2. Brief seizure review
3. Status epilepticus: the true emergency
4. Febrile seizures: not so bad
5. First unprovoked seizures: also, not so bad
1. Resuscitation basics
6. ll Pre-hospital Pediatric Seizure Care Guidelines Follow This Sequence
Initial Medical Care/Assessment
Protect Child From Injury
Vomiting and Aspiration Precautions
14. Status Epilepticus
Life Threatening Emergency
Seizures that persist without interruption > 5 mins
quential seizures without full recovery of consciousness be
Millikan D et al. Emerg Med Clin North Am. 2009
15. Status Epilepticus
Occurs in kids with epilepsy 9-27% over time
Rapid termination of seizure activity protects against neuronal injury
Millikan D et al. Emerg Med Clin North Am. 2009
16. Riviello JJ et al. Neurology. 2006
Status Epilepticus:
Types, Incidence, & Description
17. Prehospital Assessment
Assess ABCs +D x 2 (Dextrose, Disability)
Positioning (C-spine protection if trauma):
Jaw thrust/head tilt chin lift
Recovery position
Nasal airway, if needed and available
Aspiration precautions
Oxygen, Suction
18.
19. Prehospital Assessment
Obtain seizure history
How long was it?
What did it look like?
History of previous seizures (PMHx, FHx)
Current illness?
Trauma/abuse?
Length of postictal phase
20. List of current medications
Include any antipyretics given (time and dose)
Do the parents have any anticonvulsant medications (rectal diazepam)?
Have the patients given any anticonvulsant medications (time and dose)?
Prehospital Assessment
21. Prehospital Management
If actively seizing >5 mins and parent has not given rectal diazepam, administer it
Document time and dose
Continue O2, suction
Follow BLS guidelines (BVM if inadequate oxygenation)
Call EMS to transfer to ED
Obtain IV/IO access if possible and
does not delay definitive care
23. What’s a Febrile Seizure?
Caused by increase in core body temp > 100.4F (38C)
Threshold of temp which may trigger seizures is unique to each child
24. Febrile Seizure Facts
Benign
Peak occurrence: between 6 months to 5 years of age
May be either simple or complex
Accompanied by fever (before, during, after) WITHOUT ANY:
CNS infection
Metabolic disturbance
Underlying structural brain abnormality
25. 2 Types of Febrile Seizures
Simple Complex
Seizure lasting < 15 mins
Generalized
Occurs ONCE
in a 24 hour period
Seizure lasting > 15 mins
Focal
Occurs MORE THAN ONCE
in a 24 hour period
26. Prehospital Assessment
1) Assess ABCs +D x 2 (Dextrose, Disability)
2) Obtain seizure history:
How long was it?
What did it look like?
History of previous seizures (PMHx, FHx)
Current illness?
Trauma/abuse?
Length of postictal phase
3) Get a list of current meds
28. Objective #5
This kid seized for the first
time but looks great now. Do
I really have to call
neurology?
29. First Unprovoked Seizure
First seizure that occurs WITHOUT an immediate precipitating event
Etiology
Remote symptomatic:
Related to a pre-existing brain abnormality/insult
Cryptogenic/idiopathic: no known cause
Can present as a:
Partial seizure
Generalized, tonic-clonic seizure
Tonic seizure
30. Prehospital Assessment
1) Assess ABCs +D x 2 (Dextrose, Disability)
2) Obtain seizure history:
How long was it?
What did it look like?
History of previous seizures (PMHx, FHx)
Current illness?
Trauma/abuse?
Length of postictal phase
3) Get a list of current meds
32. Recurrence Risk After First Unprovoked Seizure
Majority of children will have few or no recurrences:
approximately 10-20% will have additional seizures regardless of therapy
Predictors of recurrence include:
Abnormal EEG
Underlying etiology
Abnormal neurologic exams
Remote symptomatic- recurrence risk over 2 years is > 50%
Cryptogenic/idiopathic- recurrence risk over 2 years is 30-50%
Hirtz D et al. Neurology. 2003
33. Don’t Panic. ABCDs is your mantra.
Call for help.
If actively seizing or postictal place in recovery position.
If trauma suspected, place in C-collar and jaw thrust to ensure adequate
airway
We quickly reviewed seizure classifications.
Remember, a lot of other conditions can mimic seizure
activity. Verbal and physical stimulation won’t interrupt a
seizure.
Status epilepticus is a true medical emergency
ABCDs, oxygen, suction, recovery position
Rectal diastat/IN versed
Call EMS
Simple febrile seizures need no further work up or
evaluation besides treating underlying cause for
fever
Complex febrile seizures need further evaluation
First-time unprovoked seizures may or may not need immediate
neurology consultation.
~10% of kids will have another seizure at some point
WRAP-UP
Editor's Notes
Children 2 to 5 years: 0.5 mg/kg
Children 6 to 11 years: 0.3 mg/kg
Children ≥12 years and Adults: 0.2 mg/kg
Note: Round dose to the nearest 2.5 mg increment, not exceeding a 20 mg/dose;
Gel, Rectal:
Diastat AcuDial: 10 mg (1 ea); 20 mg (1 ea)
Diastat Pediatric: 2.5 mg (1 ea) [contains alcohol, usp]
Generic: 2.5 mg (1 ea); 10 mg (1 ea); 20 mg (1 ea)
Remember: Seizure activity cannot be interrupted with verbal or physical stimulation
Repetitive non-purposeful movements
Staring
Lip-smacking
Stiffening of any or all extremities
Rhythmic shaking of any or all extremities
Psychogenic non-epileptic seizures (PNES), also known as non-epileptic attack disorders (NEAD), are events superficially resembling an epileptic seizure, but without the characteristic electrical discharges associated with epilepsy.
functional MRI has shown in some recent studies to show that they do have a sound neurological basis.
PNES are triggered by psychological problems, and frequently occur in conversion disorder. It is estimated that 20% of seizure patients seen at specialist epilepsy clinics have PNES
1/25 will have at least one febrile seizure
1/3 will have another febrile seizure
The older the child is when they have their first febrile seizure the less likely they’ll have another one
in a normal child with a simple febrile seizure the risk for subsequent epilepsy is only slightly above the general population.
The chance increases with complex febrile seizures and underlying brain abnormalities
postictal phase- altered mental status (confusion, drowsiness, nausea) after a seizure. 5-30 mins but can be prolonged after a long seizure.
Mechanism: neurotransmitter depletion, cerebral blood flow changes
If child back to baseline may be ok to asap to neuro for outpatient follow up
if deeply postictal/not back to baseline, transfer to ER for further evaluation and treatment (imaging, labs (calcium, magnesium, phosphorous, BMP, CBC, urine tox screens, pregnancy test, neuro consult, EEG)
The child who is neurologically normal, has no history of neurologic illness, and no evident acute cause for the seizure has a 24 percent risk of a recurrent seizure in the next year, and a 45 percent risk over the next 14 years, according to one large prospective study. The one year recurrence risk increases to 37 percent in children with a prior neurologic injury, and increases to 70 percent in patients who have had two seizures that are separated by at least 24 hours.