1. Evaluation and Management of Pediatric Seizures
Nikki Mehta, MD
Pediatric Neurology
Floating hospital for children at
Tufts medical center
May 9, 2019
Pediatric emergency medicine, echo lecture

2. Objectives To define seizures and epilepsy
To categorize type of seizure and identify characteristics that warrant additional evaluations
To differentiate simple from complex febrile seizure
To review treatment strategies for status epilepticus

3. Disclosures
None

4. What is a seizure?
Seizures are defined as abnormal, excessive synchronous neuronal activity in the brain
A. normal EEG
B. seizure

5. What is Epilepsy?
Epilepsy is diagnosed when a person has had 2 or more unprovoked seizures occuring greater than 24 hours apart
OR one unprovoked seizure and a probability of further seizures similar to the general recurrence risk after two seizures (60%) occuring over the next 10 years
Untreatable Tumors
Scarring from a prior infarction
The presence of an epileptogenic brain malformation
The diagnosis of an Epilepsy Syndrome

6. Classification of Seizures
Generalized
Tonic Clonic Seizure
Absence
Myoclonic
Atonic
Focal
Simple motor
Complex partial
Sensory or Autonomic

7. Partial Seizures

8. Sensory and Autonomic Seizures
Or seizures can occur in various areas of the cortex that are involved in sensory processing
Occipital Lobe- Visual Hallucinations/Auras
Medial and Lateral Temporal Lobes- Auditory Hallucinations (formed or simple)
Insular cortex – Visceral and autonomic features- nausea, emesis, sweating and flushing

9. Febrile Seizures
Common in children- up to 4% of all children <5 years of age can have them
Occur in the presence of fever, but without signs of CNS infection or other identifiable cause
Inclusion Criteria
Must fall within typical age range (6 months to 6 years)
Must be developmentally normal for age
Must not have had prior afebrile seizures
Must have fever >38F in association with the seizure

10. Simple vs Complex Febrile Seizure
Why differentiate?
Patients with Simple Febrile seizures have a near population risk of development of epilepsy
Patients with Complex Febrile Seizures have 5-10% risk of developing epilepsy

11. Simple vs Complex Febrile Seizure

12. Febrile Status Epilepticus
Febrile Seizures lasting longer than 30 minutes or recurrent episodes of same duration without neurologic recovery in between
Treat as Status Epilepticus
Consider (strongly) evaluation for CNS Infection

13. Status Epilepticus
The majority of pediatric seizures are self limited to <5 minutes
After 5 minutes, likelihood a seizure will stop on its own precipitously drops
Internalization of neuronal GABA receptors, up to 20 fold by 30 minutes
Convulsive Status Epilepticus is defined as seizure lasting >5 minutes, or recurring without return to neurologic baseline in between

14. Treatment of Seizures
Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Jan 2016
Based on large meta analysis of many RCTs treating both adults and children
Guideline is valid for all people >1 month old (same for adults and kids)

15. Stabilization Phase (0-5 min)
Airway, Breathing, Circulation, Neuro Exam
Time the seizure onset
O2 support
Establish IV access
Fingerstick Glucose and Electrolyte panel, Tox if appropriate

16. First Line Therapy Phase (5 -20 min)
If seizure continues, administer first line medication
IV Lorazepam (0.1mg/kg, max 4mg) , IV Diazepam, or IM Midazolam
Treating adequately at first is more likely to stop seizure that repeated small doses
Respiratory depression is most common side effect, expect it and prepare airway support if needed
Can repeat x 1 if seizure continues after 5 minutes

17. Second Line Therapy (20-40 min)
No clear winner for what to use next
IV Phenytoin/Fosphenytoin (20mg/kg x 1)
IV Valproic Acid (40mg/kg x 1)
IV Levetiracetam (60mg/kg x 1)
Consider transfer to center with Pediatric Neurology

18. DOI: ( / )

19. Workup: Now, Later, Never?
Now- Consider Labs, Neuroimaging, and/or EEG
Patients with clinical history of partial/focal seizure
Patients with persistent focal neurologic deficits- Seizure is a first presentation for ~50% of all Pediatric Strokes!
Patients who are not rousing/have prolonged encephalopathy beyond expected postictal period (concern for tox, NAT, encephalitis)
Patients with status epilepticus (particularly the first episode)
Later- Can be referred to outpatient Pediatric Neurology for consult and workup (1-4 weeks, depending on severity)
Patients with first afebrile seizure (of any kind), if back to baseline in ED
Patients with complex febrile seizure (clusters, prolonged), now back to baseline

20. Workup: Now, Later, Never?
Simple Febrile Seizure, meeting all inclusion criteria
+/- Complex Febrile Seizure if the reason it is complex is >2 in 24 hours