Download Pediatric Seizures

PEDIATRIC SEIZURES
Illinois Emergency Medical Services for Children
Third Edition, 2015
Illinois EMSC is a collaborative program between the Illinois Department of
Public Health and Loyola University Chicago.
Development of this presentation was supported in part by:
Grant 5 H34 MC 00096 from the Department of Health and Human Services
Administration, Maternal and Child Health Bureau
ILLINOIS EMERGENCY MEDICAL
SERVICES FOR CHILDREN (EMSC)
 Illinois EMSC is a collaborative program between the Illinois
Department of Public Health and Loyola University Chicago,
aimed at improving pediatric emergency care within our
state.
 Since 1994, The Illinois EMSC Advisory Board and several
committees, organizations and individuals within EMS and
pediatric communities have worked to enhance and
integrate:
 Pediatric education
 Practice standards
 Injury prevention
 Data initiatives
2
PROGRAM GOAL
 The goal of Illinois EMSC is to ensure that appropriate
emergency medical care is available for ill and injured
children at every point along the continuum of care.
This educational activity is being presented
without bias or conflict of interest from the
planners and presenters.
3
Acknowledgements
NOTE: This module is a
revision of original resource
published in June 2012.
Illinois EMSC Quality Improvement Subcommittee & EMSC Facility Recognition Committee
Susan Fuchs MD, FAAP, FACEP
Chair, EMSC Quality Improvement Subcommittee
Ann & Robert H. Lurie Children’s Hospital of Chicago
Carolynn Zonia, DO, FACOEP, FACEP
Chair, EMSC Facility Recognition Committee
Loyola University Health System
Paula Atteberry, RN, BSN
Illinois Department of Public Health
Joseph R. Hageman, MD, FAAP
NorthShore University Health
System - Evanston
Cheryl Lovejoy, RN, TNS
Advocate Condell Medical Center
Parul Soni, MD, MPH, FAAP
Ann & Robert H. Lurie Children’s
Hospital of Chicago
John Underwood, DO, FACEP
SwedishAmerican Hospital
Maureen Bennett, RN, BSN
Loyola University Health System
Sandy Hancock, RN, MS
Saint Alexius Medical Center
Evelyn Lyons, RN, MPH
Illinois Department of Public Health
Anita Pelka, RN
University of Chicago
Comer Children’s Hospital
LuAnn Vis, RN, MSOD, CPHQ
The Joint Commission
Mark Cichon, DO, FACOEP,
FACEP
Loyola University Health System
Melodie Havlick, RN, BSN, CEN
Rush Copley Memorial Hospital
Patrician Metzler, RN, TNS, SANE-A
Carle Foundation Hospital
Anne Porter, PhD, RN, CPHQ
Lewis University
Jim Wells, RN
Blessing Hospital
Kristine Cieslak, MD, FAAP
Central DuPage Hospital
Kathryn Janies, BA
Illinois EMSC
Michele Moran, RN
Central DuPage Hospital
Laura Prestidge, RN, BSN, MPH
Illinois EMSC
Leslie Wilkans, RN, BSN
Advocate Good Shepherd Hospital
Jacqueline Corboy, MD, FAAP
Northwest Community Hospital
Cindi LaPorte, RN
Loyola University Health System
Beth Nachtsheim Bolick, RN, MS,
DNP, CPNP-AC, PNP-BC
Rush University
Vanessa Scheidt, RN
Franciscan St James Hospital and
Health Centers
Beverly Weaver, RN, MS
Northwestern Lake Forest Hospital
Don Davidson, MD
Carle Foundation Hospital
Sue Laughlin, RN
Community Memorial Hospital
Charles Nozicka, DO, FAAP, FAAEM
Advocate Condell Medical Center
J. Thomas Senko, DO, FAAP
John H. Stroger Jr. Hospital of
Cook County
Leslie Foster, RN, BSN
OSF St. Anthony Medical Center
Daniel Leonard, MS
Illinois EMSC
Linnea O’Neill, RN, MPH
Weiss Memorial Hospital
Cathleen Shanahan, RN, BSN, MS
Ann & Robert H. Lurie Children’s
Hospital of Chicago
Special Thanks to:
Ryan Gagnon, RN
Advocate Christ Medical Center
Jammi Likes, RN, BSN,
NREMT-P
Herrin Hospital
S. Margaret Palk, MD, FAAP
University of Chicago
Comer Children’s Hospital
Herbert Sutherland, DO, FACEP
Central DuPage Hospital
Eugene Schnitzler, MD
Loyola University Health System
Jorge Asconapé, MD
Loyola University Health System
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PURPOSE
The purpose of this educational module is to
enhance the care of pediatric patients who present
with seizures through appropriate
Assessment
Management
Prevention of complications, and
Disposition (including patient &
parent/caregiver education)
Suggested Citation: Illinois Emergency Medical Services for Children (EMSC),
Pediatric Seizures, Third Edition, 2015
5
EXCLUSIONS
 Management of post traumatic seizures is
beyond the scope of this module and will
not be addressed.
 Neonatal seizures are not addressed in the
body of this module. However, information
can be found in Appendix C.
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PEDIATRIC SEIZURES
Few health care problems elicit more distress
than witnessing a child having a seizure. It is
terrifying to many. When the victim is a child,
and the observer is a parent or caregiver, that
terror can become panic.
This module seeks to aid you in minimizing that
distress and maximizing the outcome for your
patient with evidence-based guidelines.
7
OBJECTIVES
At the conclusion of this module, you will be able to:
 Manage the child with a seizure in the prehospital
and Emergency Department (ED) settings
 Identify the distinguishing characteristics between
types of seizures in the pediatric patient
 Explain the rationale for specific diagnostic testing
 Provide educational information related to care of
a child with seizures
NOTE: Hyperlinks are provided throughout the module to offer additional information
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TABLE OF CONTENTS
1.
2.
3.
4.
5.
6.
7.
Introduction and Background
Febrile Seizure
First Unprovoked Seizure
Status Epilepticus
References
Resources
Appendices



APPENDIX A – EMSC Prehospital Protocols
APPENDIX B – Sample Emergency Department Guidelines
APPENDIX C – Neonatal Seizures
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INTRODUCTION
AND
BACKGROUND
Return to Table of Contents
10
U.S. DEMOGRAPHICS 1,2
 Epilepsy affects 467,711 children 0-17 years
of age in the United States.
 300,000 people have a first seizure each year
 10% of the American population
will experience a seizure
during their lifetime
 120,000 are under 18 years of age
 Between 75,000 and 100,000 who
have experienced a febrile seizure
are under 5 years of age
11
INCIDENCE IN ILLINOIS
Inpatient and ED visits in Illinois for
0-17 year-olds with epilepsy/convulsions
as the principal or secondary diagnosis
 In 2010, 15,268 children
aged 0-17 years were
seen in the ED
 In 2011, 5,140 children
aged 0-17 years were admitted
(Source: AHRQ HCUPnet online query system, with Illinois data provided by IDPH to AHRQ.
Retrieved October 15, 2013 from http://hcupnet.ahrq.gov/)
12
ILLINOIS EMSC STATEWIDE
PEDIATRIC SEIZURE QI PROJECT
In 2010-2011, Illinois EMSC conducted a statewide
survey of Emergency Department practice patterns
(including medical record reviews) related to
children presenting with:
 Simple Febrile Seizure (SFS)
 Unprovoked Seizures (UnS), and
 Status Epilepticus (SE)
(Source: Illinois EMSC Pediatric Seizures in the Emergency Department Summary Report, May 2011)
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PEDIATRIC SEIZURE QI PROJECT
Opportunities for improvement:
 Less than half of responding facilities had a
protocol/policy/guideline/clinical pathway
that addressed the clinical management of
seizures (44%) or clinical management of SE
in particular (19%)
 In the prehospital management of pediatric seizures,
blood glucose assessments were documented in only
34% of SFS patients and slightly over half of UnS/SE
patients
 For UnS/SE patients, seizure precautions were either
not taken or not documented in more than 1/3 rd of
the cases
(Source: Illinois EMSC Pediatric Seizures in the Emergency Department Summary Report, May 2011)
14
A SEIZURE IS:
 Abnormal neuronal activity
 A sudden biochemical imbalance at the cell
membrane
 Repeated abnormal electrical discharges
 Seen clinically as changes in motor control,
sensory perception and/or autonomic
function 3
15
CLINICAL PRESENTATION:
MOTOR CHANGES
 Parents/caregivers may report seeing:
 Repetitive non-purposeful movements
 Staring
 Lip-smacking
 Falling down without cause
 Stiffening of any or all extremities
 Rhythmic shaking of any or all extremities
Seizure activity cannot be interrupted with verbal
or physical stimulation4
16
CLINICAL PRESENTATION:
SENSORY AND AUTONOMIC
 Parents/caregivers may report the child is:
 Feeling nauseous
 Feeling odd or peculiar
 Losing control of bowel or bladder
 Feeling numbness, tingling
 Experiencing odd smells or sounds
17
CLINICAL PRESENTATION:
CONSCIOUSNESS
 Consciousness is the usual alertness or
responsiveness the child demonstrates.
 Parents/caregivers may report or you may
observe the child to have:
 Baseline alertness
 Diminished level of consciousness
 Unresponsive and unconscious
18
CLINICAL PRESENTATION:
EVENTS THAT MIMIC SEIZURES
 Apnea
 Breath Holding
 Dizziness
 Myoclonus
 Pseudoseizures
 Psychogenic Seizures
 Rigors
 Shuddering
 Syncope
 Tics
 Transient Ischemic
Attacks
19
SEIZURE CLASSIFICATIONS
Generalized
Partial
Complex
Involves BOTH hemispheres
of the brain
Always involves loss of
consciousness
Types:
 Tonic or clonic movements
or combination (grand mal)
 Absence (petit mal)
 Myoclonic
 Atonic (e.g., drop attacks)
 Infantile spasms
Simple
Involves motor* or
autonomic# symptoms
with altered level of
consciousness
Can involve motor,* autonomic#
or somatosensory+ symptoms
May start in one muscle
group and spread
May start in one muscle group
and spread
Types of symptoms:
1) Motor* - head/eye deviation, jerking, stiffening
2) Autonomic# - pupillary dilatation, drooling, pallor, change in
heart rate or respiratory rate
3) Somatosensory+ - smells, alteration of perception (déjà vu)
20
GENERALIZED SEIZURE
CLASSIFICATION: DESCRIPTIONS 1
 Absence – Abrupt lapses of consciousness
lasting a few seconds
 Atonic – Abrupt, unexpected loss of
muscle tone
 Myoclonic – Rapid short contractions of
one or all extremities
21
FEBRILE SEIZURE
Return to Table of Contents
22
FEBRILE SEIZURE 5
Febrile seizures are the most common
seizure disorder in childhood,
affecting 2 - 5% of children between
the ages of 6 months and 5 years
23
FEBRILE SEIZURE 6
 Caused by the increase in the core body
temperature greater than 100.4 o F or 38 o C
 Threshold of temperature which may
trigger seizures is unique to each individual
 Can occur within the first 24 hours of an
illness
 Can be the first sign of illness in 25 - 50% of patients
24
FEBRILE SEIZURE:
CHARACTERISTICS
 Are benign
 Occurrence: between 6 months to 5 years of age
 May be either simple or complex type seizure
 Seizure accompanied by fever (before, during or
after) WITHOUT ANY
 Central nervous system infection
 Metabolic disturbance
 History of previous seizure disorder
25
FEBRILE SEIZURE: TWO TYPES 5
Simple Febrile
Complex Febrile
 6 months – 5 years of age
 Febrile before, during or
after seizure
 Includes all of the
following
 6 months – 5 years of age
 Febrile before, during or
after seizure
 One or more of the
following
 Seizure lasting less than 15
minutes
 Generalized seizure
 Occurs once in a 24-hour
period
 Prolonged (lasting more
than 15 minutes)
 Focal seizure
 Occurs more than once in
24 hours
26
FEBRILE SEIZURE:
PREHOSPITAL ASSESSMENT
 Assess the A,B,Cs
 Assess neurological status (D = Disability using AVPU)
 Obtain seizure history from a dependable witness:






How long was the seizure?
What did it look like (movements, eye deviation)?
History of previous seizures (child and family)?
Does the child have a current illness/fever?
Any indications of trauma or abuse?
Length of postictal phase?
 List current medications
 Include any antipyretics given (time and dose)
27
AVPU
T h e A VP U s c a le ( A lert , V o ic e, P a in , U n res p on s ive) is a s y s t em
b y wh ic h a h ea lth c a re p ro f es s io n a l c a n m ea s u re a n d rec o rd a
c h ild ’s level o f c o n s c io u s n es s .
T h e AV P U s ca l e s h o ul d b e a s s e s se d u s i n g t h e s e i d e nt i f iab le t ra i ts , l o o k i n g fo r
t h e b e st re s p o ns e o f e a c h :
A
V
P
U
A l e r t – t h e i n fa nt i s a c t i ve , r e s p o n s i ve t o p a re nt s a n d i n t e ra c t s
a p p ro p r i ate l y w i t h s u r ro u n d i n gs ; t h e c h i l d i s l u c i d a n d f u l l y r e s p o n s i ve ,
c a n a n s we r q u e st i o n s a n d s e e w h a t yo u ' re d o i n g .
Vo i ce – t h e c h i l d o r i n fa nt i s n o t l o o k i n g a r o u n d ; r e s p o n d s t o yo u r
vo i c e , b u t m ay b e d r o wsy, ke e p s e ye s c l o s e d a n d m ay n o t s p e a k
c o h e rent l y, o r m a ke s o u n d s .
Pa i n – t h e c h i l d o r i n fa nt i s n o t a l e r t a n d d o e s n o t r e s p o n d t o yo u r
vo i c e . Re s p o n d s t o a p a i n f u l s t i m u l u s ( e . g . , s h a k i n g t h e s h o u l d ers o r
p o s s i b l y a p p l yi n g n a i l b e d p r e s s u re ) .
U n r e s p o n s i v e – t h e c h i l d o r i n fa nt i s u n re s p o n s i ve t o a ny o f t h e
a b o ve ; u n c o n s c i o u s .
28
FEBRILE SEIZURE:
PREHOSPITAL MANAGEMENT
 Monitor the A, B, C, Ds
 Position with C-Spine protection (if trauma)
 Follow seizure and aspiration precautions
(per EMS System protocol)
 Physical exam
 Check blood glucose
 If blood glucose < 60 mg/dL, treat as appropriate
Refer to EMSC Seizure protocols (Appendix A)
29
FEBRILE SEIZURE:
ED ASSESSMENT
 Baseline assessment
 Vital signs (including temperature)
 Assess the A, B, C, Ds
 Continue providing and documenting
seizure and aspiration precautions
30
FEBRILE SEIZURE:
ED ASSESSMENT (CONT.)
 Full History
 Obtain seizure history from a dependable witness:
 When did the seizure occur?
 How long was the seizure and what did it look like?
 How was the child acting immediately before the seizure?
 History of previous seizures (child and family)?
 History of developmental delay/recent loss of milestones?
 Does the child have a current illness/fever?
 Any indications of trauma or abuse?
 Length of postictal state?
 Immunization history?
 List current medications
 Include any antipyretics given (time and dose)
31
FEBRILE SEIZURE:
ED MANAGEMENT 8
 If still having a seizure, follow Status
Epilepticus protocol
 Complete physical exam – to identify the
source of fever
 Lab testing – direct toward identifying the
source of fever
 For Simple Febrile Seizures: NO ROUTINE
LAB TESTS ARE NECESSARY
32
SIMPLE FEBRILE SEIZURE:
LUMBAR PUNCTURE
Evidence-based recommendations from the 2011
American Academy of Pediatrics (AAP) Subcommittee
on Febrile Seizures 7 are as follows:
“A lumbar puncture should be performed in any child who
presents with a seizure and a fever and has meningeal signs
and symptoms (e.g., neck stiffness, Kernig and/or Brudzinski
signs) or in any child whose history or examination suggests
the presence of meningitis or intracranial infection.”
Current data does not support routine lumbar
puncture in well-appearing, fully immunized
children who present with a simple febrile seizure.
33
SIMPLE FEBRILE SEIZURE:
LUMBAR PUNCTURE (CONT.)
Additional evidence-based recommendations from the 2011
AAP Subcommittee on Febrile Seizures 7 are as follows:
“In any infant between 6 and 12 months of age who presents with
a seizure and fever, a lumbar puncture is an option when:
- the child is considered deficient in Haemophilus influenza type b
(Hib) or Streptococcus pneumoniae immunizations (i.e., has not
received scheduled immunizations as recommended) or
- when the immunization status cannot be determined because
of an increased risk of bacterial meningitis.”
“A lumbar puncture is an option in the child who presents with
a seizure and fever and is pretreated with antibiotics, because
antibiotic treatment can mask the signs and symptoms of
meningitis.”
34
SIMPLE FEBRILE SEIZURE:
DIAGNOSTIC TESTING 5,7
EEG
Simple
Febrile
Seizure
CT/MRI
Should not be performed
in a neurologically
healthy child.
Results are not predictive of
recurrence or development
of epilepsy
Not indicated
There are no current national guidelines addressing
diagnostic testing recommendations for complex
febrile seizures.
35
SIMPLE FEBRILE SEIZURE:
ED ONGOING MANAGEMENT
 Reassess temperature
 Consider giving antipyretic
if not previously administered
 As source of fever is identified,
treat appropriately
36
SIMPLE FEBRILE SEIZURE:
FAMILY EDUCATION 5,7
Here are some frequently asked questions
parents/caregivers may have prior to discharge:
 Is my child brain damaged?
 There is no evidence of impact on learning abilities after
seizure from SFS.
 Will this happen again?
 If child is under 12 months of age at time of first seizure,
recurrence rate is 50%
 If child is greater than 12 months of age at time of first
seizure, recurrence rate is 30%
 Most recurrences occur within 6-12 months of the initial
febrile seizure
37
SIMPLE FEBRILE SEIZURE:
FAMILY EDUCATION 5,7 (CONT.)
 Will my child get epilepsy?
 For simple febrile seizures, there is no increased risk
of epilepsy
 Why not treat for possible seizures or fever?
 Anticonvulsants can reduce recurrence. However
potential side effects of medications outweigh the
minor risk of recurrence
 Prophylactic use of antipyretics does not have impact
on recurrence
For complex febrile seizures, there is a
slight increase in the risk of epilepsy.
38
SIMPLE FEBRILE SEIZURE:
FAMILY EDUCATION 8 (CONT.)
 Instruct parent/caregivers to prevent injury
during a seizure:
 Position child while seizing in a side-lying
position
 Protect head from injury
 Loosen tight clothing about the neck
 Prevent injury from falls
 Reassure child during event
 Do not place anything in the child’s mouth
39
SIMPLE FEBRILE SEIZURE:
DISPOSITION
Prior to discharge home…
 Educate regarding use of:
 Thermometer
 Antipyretics for fever management
 When to contact 9-1-1 or ambulance
 Identify a Primary Care Provider for follow -up
appointment and stress importance of follow -up
 Provide developmentally appropriate explanation
of event for child and family members
40
FEBRILE SEIZURE:
TEST YOURSELF
1. Simple Febrile Seizures:
A.
Indicate an underlying neurological
condition
B. Require anticonvulsant medication
C. Occur in children 6 months to 5 years
of age
D. Frequently lead to epilepsy
2. Which of the following are
important history questions?
A.
B.
C.
D.
Was there trauma ?
What did the seizure look like?
Medications and herbal
supplements?
All of the above
3. Diagnostic workup in the ED
is based on suspicions of:
A.
B.
C.
D.
Meningitis
Trauma
Unknown immunization status
All of the above
4. Discharge education should
include which of the
following?
A.
B.
C.
D.
Teaching about EEG results
Importance of antipyretics for
fever
Importance of follow up MRI
Teaching about anticonvulsant
medications
Proceed to next slide for answers
41
FEBRILE SEIZURE:
TEST YOURSELF: ANSWER KEY
1. Simple Febrile Seizures:
C. Occur in children 6 months to 5
years of age
2. Which of the following are
important history questions?
D.
All of the above
3. Diagnostic workup in the ED
is based on suspicions of :
D.
All of the above
4. Discharge education should
include which of the
following?
B.
Importance of antipyretics for fever
42
FIRST UNPROVOKED SEIZURE
Return to Table of Contents
43
FIRST UNPROVOKED SEIZURE 9
This is a first seizure that
occurs without an
immediate precipitating
event.
Etiology may be:
 Remote symptomatic (related to
a pre-existing brain
abnormality/insult)
 Cryptogenic or idiopathic (no
known cause)
44
FIRST UNPROVOKED SEIZURE:
PRESENTATION
Parents/caregivers may describe
symptoms consistent with the following:
 Partial seizure
 Generalized onset, tonic-clonic seizure
 Tonic seizure
Remember: this is a seizure that occurs
without an immediate precipitating event.
45
FIRST UNPROVOKED SEIZURE:
PREHOSPITAL ASSESSMENT
 Assess the A, B, C, Ds
 Obtain seizure history from a dependable witness:






How long was the seizure?
What did it look like (movements, eye deviation)?
History of previous seizures (child and family)?
Does the child have a current illness/fever?
Any indications of trauma or abuse?
Length of postictal state
 List current medications
 Include any antipyretics given (time and dose)
46
FIRST UNPROVOKED SEIZURE:
PREHOSPITAL MANAGEMENT
 Monitor the A, B, C, Ds
 Position with C-Spine protection (if trauma)
 Follow seizure and aspiration precautions
(per protocol)
 Physical assessment
 Check blood glucose
 If blood glucose < 60 mg/dL, treat as appropriate
Refer to EMSC Seizure protocols (Appendix A)
47
FIRST UNPROVOKED SEIZURE:
ED ASSESSMENT
 Baseline assessment
 Vital signs (including temperature)
 Assess the A, B, C, Ds
 Continue providing and documenting seizure
and aspiration precautions
48
FIRST UNPROVOKED SEIZURE:
ED ASSESSMENT (CONT.)
 If still seizing, follow Status Epilepticus protocol
 Full History
 Obtain seizure history from a dependable witness:
 Recent exposures (chemical, industrial)?
 When did the seizure occur?
 How long was the seizure and what did it look like?
 How was the child acting immediately before the seizure?
 History of previous seizures (child and family)?
 History of developmental delay/recent loss of milestones?
 Does the child have a current illness?
 Any indications of trauma or abuse?
 Immunization history?
 Length of postictal state?
49
FIRST UNPROVOKED SEIZURE:
ED ASSESSMENT (CONT.)
 List current medications
 Include any antipyretics given
(time and dose)
 Include anticonvulsants given
by prehospital team (time
and dose)
 Physical exam
 Head-to-toe assessment
50
FIRST UNPROVOKED SEIZURE:
DIAGNOSTIC TESTING 9
Laboratory tests are based on individual clinical
circumstances and may include:
 CBC with differential
 Blood glucose
 Electrolytes
 Calcium, magnesium, phosphorous
 Urine drug/toxicology screen
 Urine HCG (age/sex dependent)
Lumbar puncture is only indicated if there are other
symptoms that suggest a diagnosis of meningitis.
51
FIRST UNPROVOKED SEIZURE:
DIAGNOSTIC TESTING – MRI 9,10
 MRI should be considered for:
 Children under 1 year of age
 All children with significant acute cognitive
or motor impairment
 Unexplained abnormalities on neurologic exam
 Seizure of focal onset without generalization
 Abnormal EEG
 Abnormalities on MRI are seen in up to 1/3 rd of
children
 However, most abnormalities do not influence immediate
treatment or management (such as need for hospitalization)
52
FIRST UNPROVOKED SEIZURE:
DIAGNOSTIC TESTING – CT SCAN 9,10
Emergent CT Scan (without contrast) should be
considered for any child who exhibits any of the
following:
 Significant, acute cognitive
or motor impairment
 New focal deficit not
quickly resolving
 Not returned to baseline
MRI is the modality of choice, if available.
53
FIRST UNPROVOKED SEIZURE:
DIAGNOSTIC TESTING – EEG 9,10
 Obtain on ALL children in whom a nonfebrile
seizure has been diagnosed
 Can be arranged as an outpatient
 Should be interpreted by a neurologist (preferably
pediatric neurologist)
 EEG results will:
 Help predict the risk of recurrence
 Classify the seizure type or epilepsy
syndrome
 Influence the decision to perform additional
neuroimaging studies
54
FIRST UNPROVOKED SEIZURE:
ED MANAGEMENT
If child is still actively having seizures…
 Refer to Status Epilepticus protocol
When child is stable…
 Consult with Neurologist (or Intensivist)
 For possible medication recommendations
 To determine disposition:



Admit to observe
Transfer (if neurologist is unavailable)
Discharge home w/ Primary Care Provider and
Neurology follow-up
55
FIRST UNPROVOKED SEIZURE:
RECURRENCE RISK
 The majority of children who experience an
unprovoked seizure will have few or no
recurrences
 Approximately 10% will go on to have additional seizures
regardless of therapy
 Predictors of recurrence include: abnormal EEG,
underlying etiology, and abnormal neurologic
exams
 Remote symptomatic – recurrence risk over 2 years is
above 50%
 Cryptogenic or idiopathic – recurrence risk over 2 years is
30-50%
 If first seizure is prolonged, recurrent seizures are more
likely to be prolonged.
56
FIRST UNPROVOKED SEIZURE:
DRUG THERAPY 9,10
 Type of medication if offered depends on:
 Type, frequency and severity of seizures
 Side effects, titration, drug interactions,
dosing forms, cost of drug
 Neurologist preference
57
FIRST UNPROVOKED SEIZURE:
DISCHARGE & FAMILY EDUCATION
Prior to discharge home…
 Identify Primary Care Provider and Neurologist
for follow-up appointments
 Provide plan for outpatient EEG
 Provide parental support
 Consider rescue medication for home, based on
neurologist recommendation (e.g., rectal diazepam)
58
FIRST UNPROVOKED SEIZURE:
FAMILY EDUCATION 8
 Instruct parent/caregivers to prevent injury
during a seizure:
 Position child while seizing in a side-lying
position
 Protect head from injury
 Loosen tight clothing about the neck
 Prevent injury from falls
 Reassure child during event
 Do not place anything in the child’s mouth
59
FIRST UNPROVOKED SEIZURE:
FAMILY EDUCATION (CONT.)
 Instruct in use of 9-1-1 or ambulance
services
 Provide developmentally appropriate
explanation to child about the seizure
event and treatment
 Discourage swimming alone
 No driving a car until cleared by a physician
60
FIRST UNPROVOKED SEIZURE:
FAMILY EDUCATION (CONT.)
Here are some frequently asked questions
parents/caregivers may have prior to discharge:
 How likely is it that my child will have seizures again?
The risk of recurrence relates to the underlying etiology and EEG
results (normal or abnormal). The majority of children who
experience an unprovoked seizure will have few or no recurrences.
Approximately 10% will go on to have additional seizures regardless
of therapy. 9
 Is there a risk of dying from the seizure if we don’t
start medication today?
Sudden unexpected death is very uncommon (usually related to an
underlying neurologic handicap rather than seizure activity).
There are no studies showing treatment after a first seizure alters
the small risk of sudden death. 9
61
FIRST UNPROVOKED SEIZURE:
TEST YOURSELF
1. Which of the following is a true
statement regarding a First
Unprovoked Seizure:
A.
B.
C.
D.
Occurs without a precipitating event
Is never associated with an underlying
neurological condition
Always leads to epilepsy
Requires immediate initiation of
antiepileptic medication
2. Children who have a First
Unprovoked Seizure…
A.
B.
C.
D.
Should have their blood glucose
checked by ambulance staff
Could proceed to have Status
Epilepticus
Will require anti-pyretics to prevent
seizures
A and B
3. All children who have had a
First Unprovoked Seizure
should have an outpatient
EEG.
A.
B.
True
False
4. The majority of children who
have a First Unprovoked
Seizure will have few or no
recurrences.
A.
B.
True
False
Proceed to next slide for answers
62
FIRST UNPROVOKED SEIZURE:
TEST YOURSELF: ANSWER KEY
1. Which of the following is a true 3. All children who have had
statement regarding a First
a First Unprovoked Seizure
Unprovoked Seizure:
should have an outpatient
A. Occurs without a precipitating event
EEG.
A.
2. Children who have a First
Unprovoked Seizure…
D.
A and B
True
4. The majority of children
who have a First
Unprovoked Seizure will
have few or no recurrences.
A.
True
63
STATUS EPILEPTICUS
Return to Table of Contents
64
STATUS EPILEPTICUS:
DEFINITIONS 11
 Seizures that persist without interruption
for more than 5 minutes
 Two or more sequential seizures without
full recovery of consciousness between
seizures
This is a life threatening emergency
that requires immediate treatment.
65
11
STATUS EPILEPTICUS
 Commonly occurs in children with epilepsy
(9 -27% over time)
 Complications from Status Epilepticus result from
both the impact of the convulsive state on the body
systems (such as the cardiac and respiratory
systems) and the neuronal cellular injury which
leads to cell death
 Rapid termination of the seizure activity protects
against neuronal injury
66
STATUS EPILEPTICUS:
TYPES, INCIDENCE & DESCRIPTION 12
Type
Incidence
Description
33%
Status Epilepticus (SE) with no
immediate event but the child had a
previous history of CNS
malformation, traumatic brain injury
or chromosomal disorder
26%
SE with concurrent acute illness
(e.g., meningitis, encephalitis,
hypoxia, trauma, intoxication)
Febrile SE
22%
SE with a febrile illness but not a
Central Nervous System infection
(e.g., sinusitis, sepsis, upper
respiratory infection)
Cryptogenic SE
15%
SE with no identifiable cause
Remote Symptomatic SE
Acute Symptomatic SE
67
STATUS EPILEPTICUS:
PREHOSPITAL ASSESSMENT
 Assess the A, B, C, Ds
 Obtain seizure history from a dependable
witness:
 When did the seizure begin?
 What did it look like (movements, eye deviation)?
 History of previous seizures (child and family)?
 Does the child have a current illness/fever?
 Any indications of trauma or abuse?
 Emergency Information Form for Children with Special
Needs?
68
STATUS EPILEPTICUS:
PREHOSPITAL ASSESSMENT
 List current medications
 Include any antipyretics given
(time and dose)
 Do the parents have any anticonvulsant
medications (e.g., rectal diazepam)?
 Have parents given any anticonvulsant
medications (time, route and dose)?
69
STATUS EPILEPTICUS:
PREHOSPITAL ASSESSMENT
 Assess the A, B, C, Ds
 Positioning (with C-Spine protection if trauma)
 Jaw thrust
 Recovery position (side-lying)
 Provide nasal airway, if needed
 Seizure safety precautions (per protocol)
 Aspiration precautions (per protocol)
 Oxygen
 Suction
 Blood glucose testing
 If blood glucose < 60 mg/dL, treat as appropriate
70
STATUS EPILEPTICUS:
PREHOSPITAL ASSESSMENT
 If parent/caregiver has rectal diazepam and has not
given it, the parent/caregiver should be requested
to administer it
 Document time and dose
 Follow Pediatric Seizures ALS guideline
(if appropriate)
 Contact Medical Control
REFER TO APPENDIX A for EMSC Seizure Protocols
71
STATUS EPILEPTICUS:
ED GOALS OF THERAPY 11,13
Minimize seizure time as much as possible
and provide drug therapy promptly.
 Drug therapy to halt seizure
 With IV/IO access,*LORazepam IV/IO
 If no IV/IO access,
 Diazepam PR, or
 Midazolam IN
*The Institute for Safe Medication Practices recommends using
Tall Man (mixed case) letters in order to distinguish drugs with
similar sounding names – decreasing the chances of safety errors.
72
STATUS EPILEPTICUS:
ED ASSESSMENT
 Assess the A, B, C, Ds
 Full vital signs; check bedside glucose and treat
(per protocol)
 Continue to provide and document seizure and
aspiration precautions (per protocol)
 Review Prehospital History and Treatment
73
STATUS EPILEPTICUS:
ED MANAGEMENT
 Full History
 Obtain seizure history from a dependable witness:
 How long has the seizure been going on and what did






it look like when it started?
How was the child acting immediately before the
seizure?
History of previous seizures (child and family)?
History of developmental delay/recent loss of
milestones?
Does the child have a current illness?
Any indications of trauma or abuse?
Immunization history?
74
STATUS EPILEPTICUS:
ED ASSESSMENT
 Assess E (exposure)
 List current medications
 When were they last given?
 Recent exposures - chemical, industrial, infectious?
 Was patient recently out of the country?
75
STATUS EPILEPTICUS:
ED MANAGEMENT– FIRST 5 MINUTES 13
 Evaluate airway
 Suction, position and provide nasal airway as needed
 Provide 100% oxygen (non-rebreather)
 Establish vascular access
 Draw labs as determined by history (examples:)
 CBC, Electrolytes, Blood glucose, Calcium, Magnesium, Phosphorus
 Toxicology screen, if indicated by history
 Antiepileptic drug level, as indicated
 Administer benzodiazepines
 LORazepam IV/IO 0.1 mg/kg
 No IV access, give either:
Benzodiazepines may
cause respiratory
and cardiac depression.
 Diazepam PR 0.5 mg/kg (max PR dose = 20 mg) or
 Midazolam IM 0.1 mg/kg or IN 0.2 mg/kg
REFER TO APPENDIX B for sample guidelines
76
STATUS EPILEPTICUS:
ED MANAGEMENT– NEXT 10 MINUTES 13
 Reassess the A, B, Cs
 Continue supportive airway management
 Suction, position and provide nasal airway as needed
 Provide 100% oxygen (non-rebreather)
 Evaluate results of rapid blood glucose testing
If the seizure activity continues…
 Administer medications (per guidelines)
 Repeat IV LORazepam 0.1 mg/kg
 Administer IV/IM Fosphenytoin 20 mg/kg PE
PHENobarbital
is preferred in
neonates.
(Phenytoin equivalents)
REFER TO APPENDIX B for sample guidelines
77
STATUS EPILEPTICUS:
ED MANAGEMENT– NEXT 15 MINUTES 13
 Having administered 2-3 doses of
benzodiazepines, and a dose of Fosphenytoin
without halting the seizure, consider the
patient in refractory Status Epilepticus 13
 Consult with Neurology and/or Intensivist for
further management recommendations
 If available, evaluate lab results
REFER TO APPENDIX B for sample guidelines
78
STATUS EPILEPTICUS:
ED MANAGEMENT – REFRACTORY SE
 If seizure activity persists (after appropriate
doses of benzodiazepines and Fosphenytoin),
load with a second long-acting AED that was
not used initially (e.g., phenobarbital, valproic
acid, levetiracetam)
 Manage with continuous EEG monitoring
 Contact PICU/NICU to begin transfer to higher level of care
It is imperative to stop the seizure activity.
If rapid sequence induction is necessary, use short-acting
paralytics to ensure that ongoing seizure activity is not masked.
REFER TO APPENDIX B for sample guidelines
79
Status Epilepticus:
ED Management – Transfer14
 For a child in Status Epilepticus after 30 minutes
of refractory SE, enact plans to transfer to your
PICU/NICU or transport to a higher level of care
 Continued testing can be arranged in that setting
 Consider EEG with new onset SE
 Neuroimaging (CT/MRI) if etiology is unknown
REFER TO APPENDIX B for sample guidelines
80
STATUS EPILEPTICUS:
DISPOSITION
 Discuss child’s progress and advice regarding
admission or transfer based on patient status
and neurology consultation with
parents/caregiver
 Utilize a specialty/critical care transport team
 (If applicable) Explain these events to child in
developmentally appropriate manner
81
STATUS EPILEPTICUS:
PARENT EDUCATION
 Provide parents/caregivers information
regarding child’s condition and treatment plan
 Provide emotional/psychosocial support
 Encourage use of the Emergency Information
Form [developed by the American Academy of
Pediatrics (AAP) & American College of
Emergency Physicians (ACEP)] for possible
future events
82
STATUS EPILEPTICUS:
EMERGENCY INFORMATION FORM
The Emergency Information Form (EIF) for Children With Special
Needs resource was developed by the AAP and the ACEP.
 A s a s ta n d a rd i ze d m e d i ca l s u m m a r y i t h a s
 Information for prehospital and
hospital emergency care personnel
 Updates entered by caregivers
 English and Spanish versions
 24-hour accessibility
 Free, Downloadable, interactive
forms are available at the
AAP and the ACEP websites.
To be completed by both the child’s medical team and parents/caregivers.
Copies should be kept by parents, as well as on file at the PCP’s office,
subspecialist’s office, local ED, and school nurse’s office.
83
STATUS EPILEPTICUS:
TEST YOURSELF
1. You respond to a 9-1-1 call for a 4-year-old child. You find the
child on the floor of the playroom, unresponsive to voice with
rhythmic movements of both the upper and lower extremities.
The parents report that the child has had seizures, starting at age 2.
The seizure activity has always lasted only about 1 minute.
The parents called 9-1-1 when the initial seizure stopped, but the
seizure started again with about one minute in between.
They estimate the child has been seizing for about 15 minutes.
Your FIRST response is to:
A.
B.
C.
D.
Move the child to the bed
Establish vascular access
Protect/position the airway
Give rectal diazepam
Proceed to next slide for answer
84
STATUS EPILEPTICUS:
TEST YOURSELF: ANSWER KEY
1. You respond to a 9-1-1 call for a 4-year-old child. You find the
child on the floor of the playroom, unresponsive to voice with
rhythmic movements of both the upper and lower extremities.
The parents report that the child has had seizures, starting at age 2.
The seizure activity has always lasted only about 1 minute.
The parents called 9-1-1 when the initial seizure stopped, but the
seizure started again with about one minute in between.
They estimate the child has been seizing for about 15 minutes.
Your FIRST response is to:
C. Protect/position the airway
85
STATUS EPILEPTICUS:
TEST YOURSELF
2. How quickly should the first benzodiazepine be given
after Status Epilepticus begins?
A.
B.
C.
D.
At 30 m i n u te s
At 20 m i n u te s
W i t h i n 5 m i n u te s
Af te r 60 m i n u te s
3. What drugs are used first in status epilepticus?
A.
B.
C.
D.
L o ra ze pam
Fo s p he ny toin
D i a ze pam
A and C
4. Who is likely to have status epilepticus?
A.
B.
C.
D.
C h i l d wi t h a h i stor y o f e p i l e psy
C h i l d wi t h e n c e p h ali ti s
C h i l d wi t h a t ra u mati c b ra i n i n j u r y
All of the above
Proceed to next slide for answers
86
STATUS EPILEPTICUS:
TEST YOURSELF: ANSWER KEY
2. How quickly should the first benzodiazepine be given
after Status Epilepticus begins?
C. Within 5 minutes
3. What drugs are used first in status epilepticus?
D. A and C
4. Who is likely to have status epilepticus?
D. All of the above
87
References
Return to Table of Contents
88
REFERENCES
1 . E p i l e psy a n d S e i zu re S ta t i s t i cs . E p i l e psy Fo u n d at i o n . org . Ret r i ev e d O c to b e r 1 6 ,
2 0 1 3 f ro m
htt p : / / w w w.e p i l e psy fo u n d a t i o n . o rg /a b o u te p i l e psy /w h a t i s e p i l e psy /stat i st i cs . c f m .
2 . N a t i o n a l S u r v ey o f C h i l d re n ' s H e a l t h . N S C H 2 0 0 7 . D a ta q u e r y f ro m t h e C h i l d a n d
A d o l e s ce nt H e a l t h M e a s u re m e nt I n i t i a t i v e , D a ta Re s o u rc e C e nte r fo r C h i l d a n d
A d o l e s ce nt H e a l t h w e bs i te . Ret r i ev e d O c to b e r 1 6 , 2 0 1 3 f ro m
htt p : / / w w w.c h i l d h e a l t h d a ta . o rg .
3 . P i l l o w M T, H o w e s D S , D o c to r, S U. S e i zu re s . e M e d i c i n e . me d s ca pe . co m. U p d a te d
Jan 22, 2010.
4 . F i s h e r, P G . F i rs t a n d s e co n d s e i zu re : w h a t to d o a n d k n o w. C o nte m p o rar y
Pe d i a t r i c s . 2 0 0 7 ; 2 4 ( 4 ) : 8 0 - 8 9 .
5 . S te e r i n g C o m m i tte e o n Q u a l i t y I m p ro v e me nt a n d M a n a g e m e nt , S u b co mmi tte e o n
Fe b r i l e S e i zu re s . Fe b r i l e s e i zu re s : c l i n i ca l p ra c t i c e g u i d e l i n e fo r t h e l o n g - te r m
m a n a g e m e nt o f t h e c h i l d w i t h s i m p l e fe b r i l e s e i zu re s . Pe d i a t r i c s . 2 0 0 8 ; 1 2 1 : 1 2 8 1 1286.
6 . F re e d m a n S B, Po we l l E C . Pe d i a t r i c s e i zu re s a n d t h e i r m a n a g e m e nt i n t h e
e m e rg e n c y d e p a r t m e nt . C l i n Pe d E m e r g M e d . 2 0 0 3 ; 4 : 1 9 5 - 2 0 6 .
89
REFERENCES (CONT.)
7 . S te e r i n g C o m m i tte e o n Q u a l i t y I m p ro v e me nt a n d M a n a g e m e nt , S u b co mmi tte e
o n Fe b r i l e S e i zu re s . N e u ro d i a g n o st i c eva l u a t i o n o f t h e c h i l d w i t h a s i m p l e
fe b r i l e s e i zu re . Pe d i a t ri c s . 2 0 1 1 ; 1 2 7 ; 3 8 9 - 3 9 4 .
8 . A m e r i ca n A s s o ci at i o n o f N e u ro s ci e nc e N u rs e s . C a r e o f t h e p a t i e nt w i t h s e i zu re s .
2 n d e d . G l e nv i ew ( I L ) : A m e r i ca n A s s o ci a t i o n o f N e u ro s ci e n ce N u rs es ; ( Rev i s e d
2009). p23.
9 . H i r t z D, B e rg A , B ett i s D, et a l . P ra c t i c e p a ra m ete r : t re a t m e nt o f t h e c h i l d w i t h a
f i rs t u n p ro v o ke d s e i zu re : re p o r t o f t h e Q u a l i t y S ta n d a rd s S u b co mmi tte e o f t h e
A m e r i ca n A ca d e my o f N e u ro l o g y a n d t h e P ra c t i c e C o m m i tte e o f t h e C h i l d
N e u ro l o g y S o c i et y. N e u r o l o gy . 2 0 0 3 ; 6 0 : 1 6 6 - 1 7 5 .
1 0. H i r t z D, A s hw a l S , B e rg A , et a l . P ra c t i c e p a ra m ete r : eva l u a t i n g a f i rs t
n o nfe b r i l e s e i zu re i n c h i l d re n : re p o r t o f t h e Q u a l i t y S ta n d a rd s
S u b co mmi tte e o f t h e A m e r i ca n A ca d e my o f N e u ro l o g y, t h e C h i l d N e u ro l o g y
S o c i et y, a n d t h e A m e r i ca n E p i l e psy S o c i et y. N e u ro l o g y. 2 0 0 0 ; 5 5 : 6 1 6 – 6 2 3 .
90
REFERENCES (CONT.)
1 1. M i l l i ka n D, R i c e B, S i l b e rg l e i t R . E m e rg e n c y t re a t m e nt o f s ta t u s e p i l e p t i c u s :
c u r re nt t h i n k i n g . E m e r g M e d C l i n N o r t h A m . 2 0 0 9 ; 2 7 ( 1 ) : 1 0 1 - 1 1 3 .
1 2. R i v i e l l o J J J r. , A s hw a l S , H i r t z D, et a l . A m e r i ca n A ca d e my o f N e u ro l o g y
S u b co mmi tte e , P ra c t i c e C o m m i tte e o f t h e C h i l d N e u ro l o g y S o c i et y. P ra c t i c e
p a ra m ete r : d i a g n o s t i c a s s e s s me nt o f t h e c h i l d w i t h s ta t u s e p i l e p t i c u s ( a n
ev i d e n c e - b a s e d rev i ew ) : re p o r t o f t h e Q u a l i t y S ta n d a rd s S u b co mmi tte e o f
t h e A m e r i ca n A ca d e my o f N e u ro l o g y a n d t h e P ra c t i c e C o m m i tte e o f t h e
C h i l d N e u ro l o gy S o c i et y. N e u r o l o g y . 2 0 0 6 ; 6 7 ( 9 ) : 1 5 4 2 - 5 0.
1 3. G o l d s te i n J. S ta t u s e p i l e p t i c u s i n t h e p e d i a t r i c e m e rg e n c y d e p a r t m e nt . C l i n
Pe d E m e r g M e d . 2 0 0 8 ; 9 : 9 6 - 1 0 0 .
1 4. A b e n d N S , D l u g o s D J. Tre a t m e nt o f ref ra c to r y s ta t u s e p i l e p t i c u s : l i te ra t u re
rev i ew a n d a p ro p o s ed p ro to co l . Pe d i a t r N e u r o l . 2 0 0 8 ; 3 8 : 3 7 7 - 3 9 0 .
91
Online Resources
American Epilepsy Society
http://www.aesnet.org/
American Academy of Neurology Patient Education Materials
http://patients.aan.com/go/resources
CDC: Epilepsy
http://www.cdc.gov/Epilepsy/
Citizens United for Research in Epilepsy (CURE)
http://www.cureepilepsy.org/
Epilepsy Foundation: Epilepsy and Seizure Response for Law Enforcement and EMS
(free online training)
http://www.epilepsyfoundation.org/livingwithepilepsy/firstresponders/
Epilepsy Therapy Project
http://www.epilepsy.com/epilepsy_therapy_project
Return to Table of Contents
92
Video Resources
Understanding Epilepsy
www.youtube.com/watch?v=MNQlq004FkE
Types of Seizures
www.youtube.com/watch?v=CDccChHrgRA&feature=channel
Understanding Partial Seizures
www.youtube.com/watch?v=e10FSjHvV74&feature=channel
Understanding Generalized Seizures
www.youtube.com/watch?v=w5Jv0SZRwwk&feature=channel
What Causes Epilepsy?
www.youtube.com/watch?v=6NcqQkKjqTI&feature=fvw
Diagnosing Epilepsy
www.youtube.com/watch?v=HX7L11rhRTw&feature=channel
Seizure Imitators Overview
www.youtube.com/watch?v=J4xJSGpJioI&feature=relmfu
Return to Table of Contents
93
APPENDIX A
EMSC PREHOSPITAL
PROTOCOLS
Return to Table of Contents
94
EMSC PREHOSPITAL
PROTOCOLS
 All Pediatric Seizure care guidelines follow this
sequence:
 Initial Medical Care/Assessment
 Protect the child from Injury
 Vomiting and aspiration precautions
THE NEXT STEPS DEPEND
ON THE LEVEL OF CARE
OF THE RESPONDER
95
EMSC PREHOSPITAL
PROTOCOLS
Here are examples of prehospital pediatric seizure protocols
 EMERGENCY MEDICAL RESPONDER CARE GUIDELINE
 BLS CARE GUIDELINE
 ILS CARE GUIDELINE
 ALS CARE GUIDELINE
Source: Illinois EMSC Pediatric Prehospital Protocols
96
APPENDIX B
SAMPLE EMERGENCY
DEPARTMENT GUIDELINES
Return to Table of Contents
97
SAMPLE ED
SEIZURE GUIDELINES
Please give credit to any of the following resources you use
 Advocate Condell Medical Center
Pediatric Emergency Department Clinical Guideline
 Seattle Children’s Hospital
 Seizure Acute Management Pathway
(Source: Dick R and the Seizure Acute Management CSW Committee. (June, 2013). Seizure
Acute Management Pathway. Retrieved from: http://www.seattlechildrens.org /pdf/seizure acute-management-pathway.pdf )
 Febrile Seizures Pathway
(Source: Dick R and the Febrile Seizures CSW Committee. (November, 2011). Febrile Seizures
Pathway. Retrieved from: http://www.seattlechildrens.org /pdf/febrile -seizures-algorithm.pdf )
 University of Chicago Comer Children’s Hospital
Pediatric Emergency Department Clinical Guideline: Status Epilepticus
98
APPENDIX C
NEONATAL SEIZURES
Return to Table of Contents
99
NEONATAL SEIZURES
 Neonatal seizures can be difficult to diagnose
o

In neonates, onset of seizure activity is
important in determining etiology
o

May consist of very subtle and unusual physical signs
 Eye deviation, staring episodes, winking
First 24 - 72 hours of life
 Ischemic hypoxia
72 hours to 1 week of age
o
Familial neonatal seizures
 Metabolic disorders
100
NEONATAL SEIZURES
 Beyond the standard history, ask about the
pregnancy, labor and delivery and maternal
risk factors
 Physical exam should include head
circumference and careful inspection for
dysmorphic features and cutaneous lesions 9
 Consult with a pediatric neurologist to
identify infantile seizure disorders
101
NEONATAL SEIZURES:
STATUS EPILEPTICUS
 Assess the A, B, Cs
 Evaluate and maintain airway
 Provide 100% oxygen
 Establish vascular access
 Obtain rapid glucose
 Administer Medications
 PHENobarbital 20 mg/kg IV
 Repeat up to 40 mg/kg total dose
 Contact Neurology
102
THE END
103