Seizure

Objectives:

1. Understand the differential diagnosis of seizure
2. Know how to respond to a seizure
3. Understand febrile seizure evaluation
4. Describe current seizure classification
5. Understand seizure work-up and when to call pedi neurology

Articles:

• To learn about pediatric epilepsy, including key elements in evaluation of seizures, febrile seizures, and epilepsy syndromes, as well as initial management, check out these Peds in Review articles: Pediatric Seizure (2013) and Seizures in Children (2020)
• To learn about Febrile seizures: Head to this UpToDate article and be sure to check out their patient handout for great talking points. We also recommend looking at these AAP guidelines and this CHOP management algorithm.
• See this 2017 article, Operational classification of seizure types by the International League Against Epilepsy, updating seizure terminology, and accompanying companion providing guidance on how to emply the classification
• For a few more key articles, see the ER curriculum topic on seizure.

Additional Resources: 

• Print or save this handy Pediatric Epilepsy Review sheet, adapted by UMass colleagues 
• See this great short video by OPENPediatrics on acute seizure management on the wards, which goes through a case scenario
• Check out Cribsiders podcast Episode #18 Pediatric Seizures and Epilepsy: Shaking Things Up!

Self-Assessment:

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

1. Ask the nurse how long the patient has been seizing
2. Wait for your senior resident to come and assist you
3. Have the nurse give lorazepam through the IV
4. Suction and secure the airway
5. Obtain a fingerstick blood glucose

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

1. Discharge the patient home after seizure education.
2. Admit the patient to the floor for overnight observation.
3. Recommend the Emergency Department obtain a head CT.
4. Obtain screening labs including a CBCD, chemistry panel and CRP.
5. Discharge the patient home with rectal diazepam.

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

1. Administer buccal midazolam.
2. Order an emergent head CT.
3. Check electrolytes and glucose STAT.
4. Obtain more history.
5. Start a peripheral IV.

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

1. Phenytoin is used first-line in status epilepticus.
2. Phenytoin can cause cardiac arrhythmia, but fosphenytoin does not.
3. The loading dose of fosphenytoin is 20 mg/kg PE IV or IM.
4. Fosphenytoin is best used for patients with myoclonic or absence seizures.
5. Phenytoin is a prodrug.

5. A 7 month old boy is brought to the ED after he had a seizure at home. He had a runny nose and cough x3 days and a temperature of 38.3C this morning. He was given acetaminophen and the fever resolved. Later this afternoon, he was playing on the floor when he suddenly fell over and his whole body started jerking – lasting about 30 seconds, and then stopped on its own, but he was sleepy afterwards. EMS was called, at the home EMS did a fingerstick blood glucose level that was normal. In the ED, his temp is 39.1C, HR 160bpm, BP 90/60 mm Hg. He is sleepy but wakes readily during the exam. The remainder of the PE findings are normal. The boy’s parents report that he has never had a seizure before, and he has no chronic medical problems, development is age appropriate. His vaccines are up to date, with the most recent doses given at his 6 month health visit 3 weeks ago. His cousin has autism and epilepsy.

Of the following, the MOST accurate statement you can make to this boy’s parents is:

1. Electroencephalography is indicated to determine his seizure recurrence risk
2. The immunizations may have triggered this seizure
3. The short duration of the seizure makes subsequent seizures less likely
4. The strongest risk factor for recurrent seizure is his age

Find the answers here.