Illinois Emergency Medical Services for Children Third Edition, 2015

Illinois Emergency Medical Services for Children Third Edition, 2015
Pediatric Seizures Illinois Emergency Medical Services for Children Third Edition, 2015 Welcome to the Pediatric Seizures educational module. 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 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 Illinois Emergency Medical Services for Children, known as EMSC, is a collaborative initiative between the Illinois Department of Public Health and Loyola University Health System. The EMSC program is aimed at improving pediatric emergency care within the state. Since 1994, the Illinois EMSC Advisory Board, as well as several committees, organizations, and individuals within EMS and pediatric communities, have worked to enhance and integrate the pediatric component within the state’s emergency medical services system. Areas of focus include: education, practice standards, injury prevention, and data initiatives.

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. The overall goal of Illinois EMSC is to ensure that appropriate emergency medical care and resources are available for all ill and injured children at every point along the continuum of care. This educational activity is being presented without commercial support and without bias or conflict of interest from the planners and presenters. This educational activity is being presented without bias or conflict of interest from the planners and presenters.

NOTE: This module is a revision of original resource published in June 2012.
Acknowledgements 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 Anita Pelka, RN University of Chicago Comer Children’s Hospital LuAnn Vis, RN, MSOD, CPHQ The Joint Commission Mark Cichon, DO, FACOEP, FACEP 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 Laura Prestidge, RN, BSN, MPH Leslie Wilkans, RN, BSN Advocate Good Shepherd Hospital Jacqueline Corboy, MD, FAAP Northwest Community Hospital Cindi LaPorte, RN 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 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 Linnea O’Neill, RN, MPH Weiss Memorial Hospital Cathleen Shanahan, RN, BSN, MS Special Thanks to: Jorge Asconapé, MD Loyola University Health System Ryan Gagnon, RN Advocate Christ Medical Center Jammi Likes, RN, BSN, NREMT-P Herrin Hospital S. Margaret Palk, MD, FAAP Herbert Sutherland, DO, FACEP Eugene Schnitzler, MD Loyola University Health System Illinois EMSC’s oversight committees developed this module. Any information presented in this module may be used freely provided appropriate acknowledgement is cited. Citation information is listed on the next slide. Note: nothing in this module should be considered a replacement for prudent and cautious judgment of the health care provider treating the child. Every situation is unique and requires individualized care and independent treatment options.

Purpose Assessment Management Prevention of complications, and
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) The purpose of this educational module is to enhance and standardize the care of children who present with seizures. This module will address assessment, management, preventing complications, and disposition of patients presenting with simple febrile seizure, first unprovoked seizure or status epilepticus. Suggested Citation: Illinois Emergency Medical Services for Children (EMSC), Pediatric Seizures, Third Edition, 2015

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. In children, seizures can occur due to a variety of circumstances. A seizure may be the result of a traumatic event or a component of a metabolic disorder. A seizure may occur as a complication of an underlying illness or as a consequence of a medication. This module will address seizures in children in three discrete circumstances: seizure associated with fever in children six months to five years, first unprovoked seizure, and status epilepticus. Seizures that occur as a result of trauma are beyond the scope of this module. In addition, seizures which occur in infants under six months of age are very specific in both cause and treatment. Basic information about neonatal seizures can be found in Appendix C at the end of the module.

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. Seizures often occur without any warning which can make the event very emotional and terrifying to an observer. When the victim is a child, that terror can quickly become panic. The information provided will help you discuss these concerns and reframe the event for the parent or caregiver.

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 At the conclusion of this module, you will be able to identify the steps necessary in the management of a child in an emergent situation, identify distinguishing characteristics between types of seizures, explain the rationale for diagnostic testing, and provide educational information related to the care of a child with seizures. Hyperlinks can be found throughout to offer more in-depth information. NOTE: Hyperlinks are provided throughout the module to offer additional information

Table of Contents 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 This table of contents provides a snapshot of the sections that will be reviewed in this module. The appendices contain additional resource materials.

Introduction and Background
Let’s begin. Return to Table of Contents 10

U.S. Demographics1,2 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 The Epilepsy Foundation gathers statistics about the prevalence of seizures in the United States. Each year, a reported 300,000 people experience a first seizure. Of these, 120,000 are under 18 years of age.

Incidence in Illinois Inpatient and ED visits in Illinois for 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 This data reveals the impact of seizures on the healthcare system. In 2010, over 15,000 children with seizures were seen in Illinois emergency departments. In 2011, over 5,000 children were hospitalized. The image depicts the distribution of the 11 EMS regions in Illinois. (Source: AHRQ HCUPnet online query system, with Illinois data provided by IDPH to AHRQ. Retrieved October 15, 2013 from

Illinois EMSC Statewide Pediatric Seizure QI Project
In , 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) In 2010 and 2011, Illinois EMSC initiated a statewide, quality improvement project to review current treatment patterns of children who present to the emergency department with simple febrile seizures, unprovoked seizures, or status epilepticus. Over 750 simple febrile seizure and 707 unprovoked seizure and status epilepticus medical records were reviewed. (Source: Illinois EMSC Pediatric Seizures in the Emergency Department Summary Report, May 2011)

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 1/3rd of the cases Data analysis revealed some key opportunities for improvement. For example, only 44 percent of responding hospitals had a standardized seizure protocol, guideline or clinical pathway; only 19 percent addressed the clinical management of status epilepticus. Establishing evidence-based guidelines promotes streamlined care in urgent situations. Prehospital record analysis revealed that blood glucose values were only documented in 34 percent of the cases of simple febrile seizures, and 57 percent of the cases of children with unprovoked seizure and status epilepticus. A patient’s blood glucose level helps to identify hypoglycemia, which is a common reason behind an altered level of consciousness. For children presenting with unprovoked or status epilepticus, medical records revealed seizure precautions were frequently not documented, which could point to a patient safety issue. (Source: Illinois EMSC Pediatric Seizures in the Emergency Department Summary Report, May 2011)

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 function3 The next few slides review the basics of seizure activity. When a seizure occurs, there are changes at the cellular level leading to abnormal activity of the nerve endings. The biochemical imbalances result in an abnormal repetition of electrical discharges at the nerve junctions. Clinically, the child shows changes in motor control, alterations in sensory perception, and or altered autonomic function.

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 Some commonly observed motor behaviors include: repetitive, non-purposeful movements of any body part; staring; lip-smacking; falling without a cause; stiffening of any extremity; or rhythmic shaking of any extremity. If these motor behaviors can be interrupted by verbal or physical stimulation, they are not considered seizure activity. Seizure activity cannot be interrupted with verbal or physical stimulation4

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 Common sensory symptoms described by a parent or caregiver may include: feeling nauseous, odd or peculiar; losing bowel or bladder control; or feeling numb or tingling anywhere on the body. Also, experiencing odd smells or sounds may be noted.

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 The last aspect of clinical presentation is the child’s level of consciousness while experiencing the motor, sensory, and autonomic symptoms. This may vary and is compared to the child’s usual baseline level. The level of consciousness may be somewhat diminished as compared to baseline or the child may be unresponsive and unconscious.

Clinical Presentation: Events That Mimic Seizures
Apnea Breath Holding Dizziness Myoclonus Pseudoseizures Psychogenic Seizures Rigors Shuddering Syncope Tics Transient Ischemic Attacks A careful history from a reliable witness is essential in evaluating a child who presents with a reported seizure. Since witnessing a seizure can create a highly charged emotional environment, it is important to identify characteristics of seizures and consider conditions which may mimic seizures in order to make an accurate diagnosis. Breath holding, apnea, syncope, and dizziness should be considered as alternative diagnoses. Tics, myoclonus, rigors, and shuddering can be misinterpreted as changes in motor control. Psychogenic and pseudoseizures are clinically similar to epileptic seizures, but do not result from an abnormal electrical discharge from the brain.

Seizure Classifications
Generalized Partial Complex Simple Involves BOTH hemispheres of the brain Involves motor* or autonomic# symptoms with altered level of consciousness Can involve motor,* autonomic# or somatosensory+ symptoms Always involves loss of consciousness May start in one muscle group and spread Types: Tonic or clonic movements or combination (grand mal) Absence (petit mal) Myoclonic Atonic (e.g., drop attacks) Infantile spasms 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) Seizures are classified with respect to where the abnormal neuronal activity occurs. With generalized seizures, both hemispheres of the brain are involved and there is loss of consciousness. Movements are tonic or clonic or a combination. Absence seizures are also generalized. Partial seizures may be simple or complex, and involve only one hemisphere of the brain. In complex partial seizures, there is altered level of consciousness, while in simple partial seizures there is NO loss of consciousness; however, there may be transient cognitive impairments. Movements begin with a single muscle group and then spread in both complex and simple partial seizures. The different types of symptoms that may occur include motor symptoms such as - head/eye deviation, jerking, stiffening; autonomic symptoms, such as - pupillary dilatation, drooling, pallor, change in heart rate or respiratory rate, as well as somatosensory symptoms, such as smells and/or alteration of perception (for example déjà vu).

Generalized Seizure Classification: Descriptions1
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 This slide provides further descriptions of generalized seizures. Absence seizures are frequent, abrupt losses of consciousness that may be seen as staring or day-dreaming. Atonic are generalized seizures resulting in loss of muscle tone. Myoclonic are rapid, short contractions of one or all extremities.

Return to Table of Contents
Febrile Seizure The first topic reviewed is Febrile Seizures. Return to Table of Contents

Febrile Seizure5 Febrile seizures are the most common seizure disorder in childhood, affecting 2 - 5% of children between the ages of 6 months and 5 years Febrile seizures are the most common seizure disorder in childhood, affecting less than five percent of children between the ages of six months and five years.

Febrile Seizure6 Caused by the increase in the core body temperature greater than 100.4o F or 38o 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 % of patients A febrile seizure is a seizure accompanied by a fever whose cause is unknown. Each child has an unique temperature threshold that might trigger a seizure. Febrile seizures can occur within the first 24 hours of an illness, and be the first sign of illness in 25 to 50 percent of patients.

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 Febrile seizures are a benign condition. They occur in children between the ages of six months to five years. For a febrile seizure diagnosis to be established, the child must have no other history of seizures, metabolic diseases, or signs of central nervous system infections, such as meningitis. Febrile seizures can be either simple or complex.

Febrile Seizure: Two Types5
Simple Febrile 6 months – 5 years of age Febrile before, during or after seizure Includes all of the following Seizure lasting less than 15 minutes Generalized seizure Occurs once in a 24-hour period Complex Febrile 6 months – 5 years of age Febrile before, during or after seizure One or more of the following Prolonged (lasting more than 15 minutes) Focal seizure Occurs more than once in 24 hours A simple febrile seizure is defined as a generalized seizure lasting less than 15 minutes that occurs once in 24 hours. In contrast, a complex febrile seizure lasts greater than 15 minutes or has focal elements or occurs more than once in 24 hours. The American Academy of Pediatrics has developed clinical practice guidelines for evaluation and management of a simple febrile seizure. However, there are no consensus guidelines for complex febrile seizure management at this time.

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) Because a febrile seizure is usually short and self-limiting, the child who has had a febrile seizure will most likely have recovered by the time he or she enters the healthcare system. Prehospital assessment begins with a general evaluation of the child’s condition with regard to airway, breathing, and circulation. The AVPU scale can be used to assess the child’s level of consciousness. It is explained in detail on the next slide. Documenting a careful history of the seizure event from a reliable witness is essential. Directed questions can help clarify the events witnessed. Screen and assess for indications of trauma and abuse. Document all medications the child has taken, including any over-the-counter medications, herbal treatments, or antipyretics.

AVPU The AVPU scale (Alert, Voice, Pain, Unresponsive) is a system by which a healthcare professional can measure and record a child’s level of consciousness. The AVPU scale should be assessed using these identifiable traits, looking for the best response of each: A Alert – the infant is active, responsive to parents and interacts appropriately with surroundings; the child is lucid and fully responsive, can answer questions and see what you're doing. V Voice – the child or infant is not looking around; responds to your voice, but may be drowsy, keeps eyes closed and may not speak coherently, or make sounds. P Pain – the child or infant is not alert and does not respond to your voice. Responds to a painful stimulus (e.g., shaking the shoulders or possibly applying nail bed pressure). U Unresponsive – the child or infant is unresponsive to any of the above; unconscious. The AVPU scale, which stands for Alert, Voice, Pain, and Unresponsive, is a system by which a healthcare professional can measure and record a child’s level of consciousness. The AVPU scale should be assessed using these identifiable traits, looking for the best response in each. A stands for ALERT. In this category, the child is lucid and fully responsive, can answer your questions, and can see what you're doing. In infants, they appear active, are responsive to their parents, and interact appropriately with their surroundings. If the child is not awake and alert, do they respond to sound? If yes, then classify their level of consciousness as V. V is for VOICE. The child or infant responds to your voice, but may be drowsy. They are not looking around; they keep their eyes closed and may speak incoherently or make sounds. P is for PAIN. The child or infant is not alert and does not respond to your voice, but does respond to a painful stimulus, such as shaking the shoulders or possibly applying pressure to a nail bed. U is for UNRESPONSIVE. This child or infant is unresponsive to any of the above; is unconscious.

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) Following the EMSC Prehospital Seizures protocol, prehospital management focuses on assuring a safe environment and checking the blood glucose since hypoglycemia can be a trigger for seizures. Refer to the EMSC Prehospital protocols found in Appendix A for detailed instructions. 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 In the Emergency Department, care begins with a general assessment of the child. Seizure and safety precautions should be implemented, as outlined by your individual institution. Assess and document all vital signs, including the child’s temperature.

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) A complete history from a reliable witness is essential. Questions about the seizure, as well information about the child’s baseline behavior, will help with the differential diagnosis. Obtaining this data set will assist the physician in providing timely care. Screen and assess for indications of trauma and abuse. Obtain a list of medications the child is taking, including over-the-counter medications. 31

Febrile Seizure: ED Management8
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 If the child continues to have a seizure, it is important to minimize seizure time and provide drug therapy promptly, as indicated in the status epilepticus protocol. Once the child is stable, conduct a complete physical examination. Current simple febrile seizure guidelines from the American Academy of Pediatrics indicate no evidence to support the benefits of routine blood studies. Any lab work ordered should be directed toward the determination of the source of the fever rather than the source of the seizure.

Simple Febrile Seizure: Lumbar Puncture
Evidence-based recommendations from the 2011 American Academy of Pediatrics (AAP) Subcommittee on Febrile Seizures7 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.” Similarly, the American Academy of Pediatrics’ guidelines do not support performing routine lumbar puncture testing. The guidelines do recommend performing a lumbar puncture if the 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.

Simple Febrile Seizure: Lumbar Puncture (cont.)
Additional evidence-based recommendations from the 2011 AAP Subcommittee on Febrile Seizures7 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.” In addition, a lumbar puncture may be considered if the child’s immunization status is deficient or unknown due to the increased risk of bacterial meningitis. Meningitis should also be considered in the child who has been on antibiotic therapy as this may mask meningeal symptoms. It should be noted that seizure activity is rarely the only symptom in a febrile child who has meningitis.

Simple Febrile Seizure: Diagnostic Testing5,7
EEG CT/MRI Simple Febrile Seizure Should not be performed in a neurologically healthy child. Results are not predictive of recurrence or development of epilepsy Not indicated The American Academy of Pediatrics’ guidelines recommend neuroimaging should not be performed as part of a routine evaluation of a child with a simple febrile seizure. If the child has a complex febrile seizure, an EEG and CT or MRI can be helpful, but this can be performed as an outpatient. There are no current national guidelines addressing diagnostic testing recommendations for complex febrile seizures.

Simple Febrile Seizure: ED Ongoing Management
Reassess temperature Consider giving antipyretic if not previously administered As source of fever is identified, treat appropriately Emergency Department management focuses on reassessment of the child’s temperature, administration of antipyretics as ordered by the physician, and appropriate treatment for the source of the fever, when identified.

Simple Febrile Seizure: Family Education5,7
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 Febrile seizures are a benign condition. There is no evidence of learning disabilities from febrile seizures. The largest risk is recurrence. The risk of recurrence is related to the age of the child at the time of the first seizure. If a child is under 12 months of age at the time of first seizure, the recurrence rate is 50%. If the child is greater than 12 months at the time of the first seizure, the recurrence rate is 30%.

Simple Febrile Seizure: Family Education5,7 (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 Research indicates there is no increased risk of epilepsy if a child had a simple febrile seizure. While anticonvulsants can reduce the minor risk of recurrence, potentially negative side effects outweigh the benefit. Similarly, prophylactic use of antipyretics is not effective in preventing recurrent febrile seizures. For complex febrile seizures, there is a slight increase in the risk of epilepsy.

Simple Febrile Seizure: Family Education8 (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 Family education should include instruction to protect the child during the seizure. Seizure precautions revolve around protecting the child from injury, such as positioning the child in a side-lying fashion, protecting the head, loosening tight clothing about the neck, and reassuring the child. Remind parents and caregivers they should not place objects in the child’s mouth to avoid tongue biting or swallowing.

Simple Febrile Seizure: Disposition
Prior to discharge home… Educate regarding use of: Thermometer Antipyretics for fever management When to contact 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 Although antipyretic treatment has not been shown to be effective in the prevention of recurrence, parents and caregivers do still need instruction on fever management based on the source of the fever. Reviewing appropriate use of or ambulance transport is also important. Many recommend calling after 5 minutes of seizure activity or if the child doesn’t regain consciousness between seizures. Typically, children who have had a simple febrile seizure are discharged home with primary care follow-up. Older children will need explanation in an age appropriate way to understand the experience in a non-threatening way.

Febrile Seizure: Test Yourself
1. Simple Febrile Seizures: Indicate an underlying neurological condition Require anticonvulsant medication Occur in children 6 months to 5 years of age Frequently lead to epilepsy 3. Diagnostic workup in the ED is based on suspicions of: Meningitis Trauma Unknown immunization status All of the above 2. Which of the following are important history questions? Was there trauma ? What did the seizure look like? Medications and herbal supplements? All of the above 4. Discharge education should include which of the following? Teaching about EEG results Importance of antipyretics for fever Importance of follow up MRI Teaching about anticonvulsant medications Proceed to next slide for answers These questions will help you evaluate your learning from this first topic: febrile seizures. Proceed to the next slide for the correct answers.

Febrile Seizure: Test Yourself: ANSWER KEY
1. Simple Febrile Seizures: C. Occur in children 6 months to 5 years of age 3. Diagnostic workup in the ED is based on suspicions of: All of the above 2. Which of the following are important history questions? All of the above 4. Discharge education should include which of the following? Importance of antipyretics for fever

First Unprovoked Seizure
The next topic to be discussed is first unprovoked seizure. Return to Table of Contents

First Unprovoked Seizure9
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) A first unprovoked seizure is a seizure that occurs without an immediate precipitating event in the absence of fever. Occurrence suggests a potential underlying neurological condition that predisposes the child to recurrent seizures. An unprovoked seizure may be due to a yet undiagnosed brain abnormality, genetic or cryptogenic.

First Unprovoked Seizure: Presentation
Parents/caregivers may describe symptoms consistent with the following: Partial seizure Generalized onset, tonic-clonic seizure Tonic seizure Presentation may be consistent with partial seizure, generalized tonic-clonic or tonic seizure. To be classified as first unprovoked, there must be no history of previous seizures and no immediate precipitating cause such as fever, trauma or infection. Remember: this is a seizure that occurs without an immediate precipitating event.

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) A child who has had a seizure without fever may present appearing in a normal state or may have some alterations in alertness. Begin with assessment of airway, breathing, circulation, and disability. A complete history from a reliable witness is essential in determining the details of the seizure. Screen and assess for indications of trauma and abuse. Obtain a list of medications the child is taking, including over-the-counter medications and antipyretics. Determine the child’s level of alertness and document the presence of any postictal behaviors. Assess for hypoglycemia which can cause an alteration in alertness.

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) Management includes ongoing monitoring of the child’s airway, breathing, circulation, and neurological state. Continue seizure and aspiration precautions. The physical exam should include evaluation of the blood glucose level. Please refer to the EMSC Prehospital Seizure protocol located in Appendix A of this module for more detail. 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 In the Emergency Department, the assessment begins with an evaluation of the child’s current status with full vital signs, including temperature, to verify that this is not a febrile seizure. Seizure and aspiration precautions should be followed and documented, per your institution’s policy.

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? If the child continues having siezures, it is important to minimize seizure time and provide drug therapy promptly as indicated in your status epilepticus protocol. Once the child is stable, obtain a full history from a dependable witness of the seizure event. Ask about the time of the seizure, how long it lasted, and what kinds of behaviors the child displayed. This information is especially vital if the child has returned to baseline behavior before arrival to the emergency department. Ask about previous seizure activity, loss of developmental milestones, current illnesses, exposures, and trauma. Remember to screen and assess for evidence of trauma or abuse.

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 As described previously, obtain a complete medication list including antipyretics or anticonvulsants. The physical exam should be a complete head-to-toe assessment.

First Unprovoked Seizure: Diagnostic Testing9
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) Laboratory tests are based on the information gathered in the history and physical to evaluate potential diagnoses. Lumbar puncture is only indicated if there are other signs and symptoms suggesting meningitis. Lumbar puncture is only indicated if there are other symptoms that suggest a diagnosis of meningitis.

First Unprovoked Seizure: Diagnostic Testing – MRI9,10
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 1/3rd of children However, most abnormalities do not influence immediate treatment or management (such as need for hospitalization) If neuroimaging is recommended, MRI is the modality of choice. Due to the potential need for sedation with MRI, this study is usually done on an outpatient basis. Children in whom an MRI may be indicated include those under the age of one year, children with significant cognitive or motor impairment, or those with unexplained abnormalities on their neurological exam. Also, consider an MRI if the seizure is focal in nature and in those with an abnormal EEG.

First Unprovoked Seizure: Diagnostic Testing – CT Scan9,10
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 An emergent CT scan should be considered as part of the Emergency Department management if the child has significant cognitive or motor impairment, exhibits a focal deficit not resolving or has not returned to baseline, or if the MRI is not available. MRI is the modality of choice, if available. 53

First Unprovoked Seizure: Diagnostic Testing – EEG9,10
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 An EEG should be obtained on all children who have had a nonfebrile seizure. This can be arranged as an outpatient and should be done in coordination with a neurologist, preferably a pediatric neurologist, who will then read the EEG. The EEG results will help predict the risk of recurrence, classify the seizure type, and influence decisions about further imaging studies.

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 Remember, if the child is actively having seizures, minimize seizure time as much as possible by providing prompt drug therapy. Treatment of a child with a first unprovoked seizure is dependent on consultation with a neurologist. Based on the clinical findings and the neurologist recommendation, disposition of the child may include: admission to the hospital for observation, transfer to another facility or discharge home with instructions to follow up with a neurologist.

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. Most children who experience an unprovoked seizure will have few or no recurrences. Approximately ten percent will go on to have additional seizures regardless of therapy. Predictors of recurrence include having an abnormal EEG, an abnormal neurologic exam, and a prolonged first seizure.

First Unprovoked Seizure: Drug Therapy9,10
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 If drug therapy is warranted, the type of medication prescribed will depend on the type of seizure, potential side effects, co-morbidities, and cost considerations as well as the preference of the neurologist.

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) If the decision is made to discharge the child home, ensure follow-up with primary care and a neurologist. Arrange for the outpatient EEG, either by scheduling the test or provide the parents/caregivers with the necessary information as part of the discharge plans. Review appropriate safety issues to prevent injury. Based on the neurologist recommendations, provide parental support and answer questions for a smooth transition home.

First Unprovoked Seizure: Family Education8
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 Instruct parents and caregivers about seizure precautions for their child.

First Unprovoked Seizure: Family Education (cont.)
Instruct in use of 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 Remember to discuss the appropriate use of emergency services if the child is seizing. Developmental explanations of the event will ease the child’s fear or anxiety. For all children, swimming should not be done alone. For the older child, driving is not allowed until cleared by the physician.

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 Here are some questions your parent may ask at discharge. Recurrence relates to the underlying cause of the unprovoked seizure. Fortunately, sudden death subsequent to seizure activity is a rare event. And, there are no studies demonstrating anticonvulsant therapy after the first seizure will alter this small risk of sudden death.

First Unprovoked Seizure: Test Yourself
1. Which of the following is a true statement regarding a First Unprovoked Seizure: Occurs without a precipitating event Is never associated with an underlying neurological condition Always leads to epilepsy Requires immediate initiation of antiepileptic medication 3. All children who have had a First Unprovoked Seizure should have an outpatient EEG. True False 2. Children who have a First Unprovoked Seizure… 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 4. The majority of children who have a First Unprovoked Seizure will have few or no recurrences. True False Proceed to next slide for answers These questions will help you evaluate your learning from this first topic: febrile seizures. Proceed to the next slide for the correct answers.

First Unprovoked Seizure: Test Yourself: ANSWER KEY
1. Which of the following is a true statement regarding a First Unprovoked Seizure: Occurs without a precipitating event 3. All children who have had a First Unprovoked Seizure should have an outpatient EEG. True 4. The majority of children who have a First Unprovoked Seizure will have few or no recurrences. True 2. Children who have a First Unprovoked Seizure… A and B

Status Epilepticus The third topic to be discussed is status epilepticus. Return to Table of Contents

Status Epilepticus: Definitions11
Seizures that persist without interruption for more than 5 minutes Two or more sequential seizures without full recovery of consciousness between seizures Status epilepticus is a life-threatening emergency that requires immediate treatment. This condition is defined as seizures that persist causing a wide spectrum of clinical symptoms and with a highly variable pathophysiological, anatomical, and etiological basis. It consists of two or more sequential seizures without full recovery of consciousness between seizures. This is a life threatening emergency that requires immediate treatment.

Status Epilepticus11 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 Status epilepticus commonly occurs in children with epilepsy. Simple febrile seizure and first unprovoked seizure may also progress to status epilepticus. Complications from status epilepticus result from both the impact of the convulsive state on the body systems, such as cardiac and respiratory systems, as well as the neuronal cellular injury, which leads to cell death. Rapid termination of the seizure activity protects against neuronal injury.

Status Epilepticus: Types, Incidence & Description12
Remote Symptomatic SE 33% Status Epilepticus (SE) with no immediate event but the child had a previous history of CNS malformation, traumatic brain injury or chromosomal disorder Acute Symptomatic SE 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 The four most common types of status epilepticus are remote symptomatic, acute symptomatic, febrile, and cryptogenic. Each description shows identifiable causes, except for cryptogenic which has no identifiable cause.

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? The prehospital assessment of a child in status epilepticus begins with assessment of airway, breathing, circulation, and neurological status. A directed seizure history includes questions about how long it has been going on, how the child was behaving, and history of previous seizures. Document all complaints of current illnesses, and any evidence of trauma or abuse. If the child has special healthcare needs, ask if the family uses an Emergency Information Form that could expedite care.

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)? Obtain a list of medications the child is taking, including over-the-counter medications. If the parents or caregivers have anticonvulsant medications at home, they should be encouraged to administer the medication. Document the time, route and dose of any medication administered, either by a family member or prehospital personnel.

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 Following the initial assessment, provide what is necessary to support the respiratory status of the child, such as inserting a nasal airway. Place the child in a side-lying position and jaw thrust to support the respiratory status. Seizure, safety and aspiration precautions should be maintained, as per protocol. Assess the child’s blood glucose level; treat as appropriate.

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 Establish contact with Medical Control. If the parent or caregiver has been prescribed rectal diazepam for the child, they should be instructed to administer it. Some ALS-level providers have protocols to administer rectal diazepam, and should follow their protocol, as appropriate. Refer to the EMSC Prehospital Seizure protocol found in Appendix A for more details. REFER TO APPENDIX A for EMSC Seizure Protocols

Status Epilepticus: ED Goals of Therapy11,13
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 To improve outcomes, current research stresses the importance of administering benzodiazepines promptly to minimize seizure activity. The specific agent will vary depending on intravenous or intraosseous access and your hospital’s seizure protocol. Remember, if you cannot quickly obtain IV or IO access, consider administering rectal diazepam or intranasal midazolam to effectively halt seizure activity. *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.

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 In the Emergency Department, thoroughly assess the child’s airway, breathing, circulation and neurological status. Document a full set of vital signs. Assess the blood glucose level and treat, as per protocol. Seizure, safety, and aspiration protocols should be followed. EMS history and treatment already given should be noted.

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? A full, directed history should be obtained from a dependable witness. Ask about the beginning of the seizure episode, behavior before the seizure began, history of previous seizures, family history of seizures, and loss of milestones. Document all complaints of current illnesses, and any evidence of trauma or abuse. Document the child’s current immunization status.

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? As you continue the patient assessment, obtain a complete medication history including the last dose administered. Consider any environmental, chemical, industrial or infectious exposures the child may have experienced. In addition, recent travel outside of the country could be pertinent to the child’s condition.

Status Epilepticus: ED Management– First 5 Minutes13
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: Diazepam PR 0.5 mg/kg (max PR dose = 20 mg) or Midazolam IM 0.1 mg/kg or IN 0.2 mg/kg Benzodiazepines may cause respiratory and cardiac depression. Status epilepticus is a medical emergency and requires prompt intervention to stop the seizure activity. Within the first five minutes of arrival to the Emergency Department, the child should receive a benzodiazepine medication. This type of medication can cause respiratory and cardiac depression so the child should be closely monitored. Collect additional lab work based on history to elucidate a cause. REFER TO APPENDIX B for sample guidelines

Status Epilepticus: ED Management– NEXT 10 Minutes13
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 (Phenytoin equivalents) PHENobarbital is preferred in neonates. If the seizure does not stop after the first five minutes of treatment, administer a long acting antiepileptic medication such as Fosphenytoin. If seizures persist after this point, a decision must be made regarding the ability of the facility to manage this patient long term. Consider admission to a higher level of care or transport to another facility. Refer to Appendix B for sample status epilepticus guidelines. REFER TO APPENDIX B for sample guidelines 77

Status Epilepticus: ED Management– NEXT 15 Minutes13
Having administered 2-3 doses of benzodiazepines, and a dose of Fosphenytoin without halting the seizure, consider the patient in refractory Status Epilepticus13 Consult with Neurology and/or Intensivist for further management recommendations If available, evaluate lab results If the child continues to seize, consult with a neurologist or an intensivist. After administering 2 to 3 doses of drugs, as indicated by protocol, the child is considered in refractory status epilepticus. The child will require additional hospitalization and escalation of drug therapy. REFER TO APPENDIX B for sample guidelines

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 If the seizure activity is not controlled with these interventions, broaden your differential and think about other causes, especially toxic ingestions. More suggestions can be found in the sample guidelines in Appendix B. It is imperative to stop the seizure. However, respiratory depression is common with many of the medications used to halt the seizure. If the child requires endotracheal intubation for airway protection and support, use only a short-acting agent for muscle relaxation, as these agents mask the fact that there is ongoing seizure activity. Begin or continue conversations with a pediatric neurologist or intensivist for recommendations about management of the patient and to arrange transfer. 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

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 For a child in refractory status epilepticus, initiate the admission process to a higher level of care within your hospital or transport to another facility. Additional neuroimaging can be obtained in that setting. 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 Update the parents or caregivers regarding the progress of their child, and need for additional intervention in an alternative location. Utilize an appropriate specialty or critical care transport team when transferring to a higher level of care. If the child is alert, explain what is happening in a developmentally appropriate manner to lessen the trauma.

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 Parent and caregiver education will depend on the child’s response to treatment, consultation with the neurologist, and plan of care. It is important to remember the emotional aspects of status epilepticus on the parent or caregiver. When appropriate, encourage the use of the Emergency Information Form.

Status Epilepticus: Emergency Information Form
The Emergency Information Form (EIF) for Children With Special Needs resource was developed by the AAP and the ACEP. As a standardized medical summary it has 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. The Emergency Information Form for Children with Special Needs resource was developed by the American College of Emergency Physicians and the American Academy of Pediatrics. The resource is intended to expedite emergency care of children with complicated health histories. 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.

Status Epilepticus: Test Yourself
1. You respond to a 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 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: Move the child to the bed Establish vascular access Protect/position the airway Give rectal diazepam Proceed to next slide for answer The questions on the following slides will help you evaluate your understanding of status epilepticus. Proceed to the next slide for the correct answer to this case study.

Status Epilepticus: Test Yourself: Answer Key
1. You respond to a 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 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: Protect/position the airway The questions on the following slides will help you evaluate your understanding of status epilepticus. Proceed to the next slide for the correct answer to this case study.

Status Epilepticus: Test Yourself
2. How quickly should the first benzodiazepine be given after Status Epilepticus begins? A. At 30 minutes B. At 20 minutes C. Within 5 minutes D. After 60 minutes 3. What drugs are used first in status epilepticus? A. Lorazepam B. Fosphenytoin C. Diazepam D. A and C 4. Who is likely to have status epilepticus? A. Child with a history of epilepsy B. Child with encephalitis C. Child with a traumatic brain injury D. All of the above Proceed to next slide for answers

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

References Return to Table of Contents

References Epilepsy and Seizure Statistics. EpilepsyFoundation.org. Retrieved October 16, 2013 from National Survey of Children's Health. NSCH Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved October 16, 2013 from Pillow MT, Howes DS, Doctor, SU. Seizures. eMedicine.medscape.com. Updated Jan 22, 2010. Fisher, PG. First and second seizure: what to do and know. Contemporary Pediatrics. 2007;24(4):80-89. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121: Freedman SB, Powell EC. Pediatric seizures and their management in the emergency department. Clin Ped Emerg Med. 2003;4:

References (cont.) Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127; American Association of Neuroscience Nurses. Care of the patient with seizures. 2nd ed. Glenview (IL): American Association of Neuroscience Nurses; (Revised 2009). p23. Hirtz D, Berg A, Bettis D, et al. Practice parameter: treatment of the child with a first unprovoked seizure: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2003;60: Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children: report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000;55:616–623.

References (cont.) Millikan D, Rice B, Silbergleit R. Emergency treatment of status epilepticus: current thinking. Emerg Med Clin North Am. 2009;27(1): Riviello JJ Jr., Ashwal S, Hirtz D, et al. American Academy of Neurology Subcommittee, Practice Committee of the Child Neurology Society. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9): Goldstein J. Status epilepticus in the pediatric emergency department. Clin Ped Emerg Med. 2008;9: Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol. 2008;38:

Online Resources American Epilepsy Society American Academy of Neurology Patient Education Materials CDC: Epilepsy Citizens United for Research in Epilepsy (CURE) Epilepsy Foundation: Epilepsy and Seizure Response for Law Enforcement and EMS (free online training) Epilepsy Therapy Project Return to Table of Contents

Video Resources Understanding Epilepsy Types of Seizures Understanding Partial Seizures Understanding Generalized Seizures What Causes Epilepsy? Diagnosing Epilepsy Seizure Imitators Overview Return to Table of Contents

APPENDIX A EMSC Prehospital Protocols
Appendix A contains examples of prehospital seizure guidelines. Return to Table of Contents

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

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

APPENDIX B Sample Emergency Department Guidelines
Appendix B contains examples of emergency department seizure guidelines. Return to Table of Contents

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: Febrile Seizures Pathway (Source: Dick R and the Febrile Seizures CSW Committee. (November, 2011). Febrile Seizures Pathway. Retrieved from: University of Chicago Comer Children’s Hospital Pediatric Emergency Department Clinical Guideline: Status Epilepticus

APPENDIX C Neonatal Seizures
Appendix C contains some general information about neonatal seizures. Return to Table of Contents

Neonatal Seizures Neonatal seizures can be difficult to diagnose
May consist of very subtle and unusual physical signs Eye deviation, staring episodes, winking In neonates, onset of seizure activity is important in determining etiology First hours of life Ischemic hypoxia 72 hours to 1 week of age Familial neonatal seizures Metabolic disorders

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 lesions9 Consult with a pediatric neurologist to identify infantile seizure disorders

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

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Illinois Emergency Medical Services for Children Third Edition, 2015

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