Pediatric Seizure

Key considerations: Status epilepticus, Meningitis / Encephalitis, Intracranial hemorrhage (NAT)

Cannot miss

history: Duration, type of movement, focality; Preceding fever (febrile seizure?); Developmental history; Family history of seizures/epilepsy; Possible ingestion or toxic exposure; Recent head trauma, bruising; exam: Post-ictal state: duration of altered consciousness; Fontanelle (bulging = increased ICP); Pupils and eye deviation; Focal neurological deficits; Signs of trauma or NAT (bruising in non-mobile infant); Skin: neurocutaneous stigmata (NF, tuberous sclerosis); labs: Point-of-care glucose IMMEDIATELY; BMP: sodium, calcium, magnesium; CBC if febrile — consider LP if <12 months with fever and seizure; Anti-epileptic drug levels if on medications; Toxicology screen if ingestion suspected; imaging: CT head: if focal seizure, prolonged post-ictal state, trauma concern, or NAT; MRI brain: first afebrile seizure workup (can be outpatient); bedside: Continuous monitoring during post-ictal phase; Point-of-care glucose; Temperature

immediate: ABCs — supplemental O2, position of safety; Check glucose immediately — correct if <60mg/dL; If actively seizing >5 min: benzodiazepine; general: Time the seizure from the start; Protect airway but do NOT put anything in the mouth; specific: diagnosis: Status epilepticus; steps: Midazolam 0.2mg/kg IM/IN (max 10mg) or Lorazepam 0.1mg/kg IV (max 4mg); Repeat benzodiazepine x1 if still seizing at 5 min; If still seizing: Levetiracetam 60mg/kg IV (max 4500mg) or Fosphenytoin 20mg PE/kg IV; If refractory: prepare for RSI and continuous infusion (midazolam drip); diagnosis: Simple febrile seizure; steps: Reassurance — excellent prognosis, 2-5% lifetime epilepsy risk (similar to general population); Antipyretics for comfort (do NOT prevent recurrence); No routine labs, imaging, or EEG needed; Counsel on recurrence risk (~30% if first before age 1); diagnosis: First afebrile seizure; steps: Observation in ED for recurrence; Labs: BMP, glucose, consider toxicology; Outpatient neurology referral and EEG; Do NOT start anti-epileptic unless recurrent seizures

admit: Status epilepticus; Persistent altered mental status; First afebrile seizure with abnormal neuro exam; Suspected meningitis or NAT; Metabolic derangement requiring correction; discharge: Simple febrile seizure with return to baseline; Known epilepsy with breakthrough seizure, back to baseline, therapeutic drug levels; First afebrile seizure with normal exam and reliable follow-up; consults: Pediatric neurology for first afebrile seizure; Child protective services if NAT suspected

Simple febrile seizure: age 6mo-5yr, generalized, <15min, single in 24hr, normal neuro exam — NO workup needed
LP should be strongly considered in febrile seizure <12 months, especially if not fully immunized
Buccal/intranasal midazolam is as effective as IV lorazepam and faster to administer — use when no IV
Hypoglycemia is a TREATABLE cause of seizures — check glucose in every seizing child immediately

AAP Febrile Seizure Guidelines 2011, Pediatric Status Epilepticus Guidelines (NCS 2012). Last reviewed: 2024-11-01