Convulsions in Pediatric Emergency

Afebrile convulsions and status epilepticus

Most convulsions are brief and do not require any specific treatment Convulsions may be generalized and tonic-clonic in nature but can also be focal. Generalized convulsive status epilepticus (CSE) is currently defined as a convulsion lasting 30 minutes or more or when successive convulsions occur so frequently that the patient does not recover consciousness between convulsions. Tonic-clonic status occurs in up to 5% of patients with primary epilepsy and about 5% of children with febrile seizures may present with CSE.

Management of the convulsion

The primary assessment should be as for any seriously ill child. A structured approach to the primary survey is particularly important; if a problem is found during the initial ABCDE assessment then immediate treatment and resuscitation should occur,remembering to treat the treatable as you progress through the primary survey. In a fitting child never forget to check the glucose and treat hypoglycemia appropriately. If a convulsion occurs, position the child in a semiprone position to minimise the chance of aspiration. If necessary and possible, clear the airway with gentle suction and give oxygen via the facemask.

If the convulsion continues for more than 10 minutes then follow the flow chart in pict below.

Give high-flow oxygen via facemask, monitor oxygen saturation and test the glucose level. A short acting benzodiazepine should then be administered. The nature and dose of the drug will depend on whether intravenous access had been obtained and on departmental guidelines. Some antiepileptics such as paraldehyde are used in some countries but not others.

Convulsions management and treatment in Pediatric Emergency

a. If venous access or intraosseous access has been obtained

The following drugs can be given in sequence if fitting continues:

• Lorazepam 0.1 mg/kg weight i.v. or intra-osseous (i.o) can be given and repeated after 10 minutes if necessary. This is currently the drug of choice in the latest Advanced Pediatric Life Support Guidelines in the UK, USA and Australia. Diazepam 0.25 mg/kg weight or midazolam 0.15mg/kg weight are alternatives to lorazepam. They can be repeated after 5 minutes if seizures continue. The child needs to be monitored carefully for respiratory depression.

• Paraldehyde 0.4 ml/kg weight per rectum (p.r.) is given 10 minutes after the benzodiazepines if necessary, but is not available in Australia.

• Phenytoin 18 mg/kg weight i.v. or i.o. as a loading dose in normal saline over 30 minutes can then be given with ECG monitoring. If the child is already on phenytoin, then i.v. phenobarbitone 15–20 mg/kg weight can be used over 10 minutes. In neonates, phenobarbitone is often used as the drug of choice.

• If fitting still continues, seek senior anesthetic and medical advice and assistance. The child may require rapid sequence induction and intubation with thiopentone 4 mg/kg weight i.v. or i.o. Muscle relaxants should not be used long term.

b. If venous access has not been obtained

• Diazepam 0.25–0.5 mg/kg weight rectally or midazolam 0.15 mg/kg weight i.v. can be given.

• After 10 minutes, give paraldehyde 0.4 ml/kg weight p.r. (0.4ml of paraldehyde plus 0.4 ml of olive oil=0.8 ml/kg weight of prepared solution), but this is not a choice in Australia.

• Seek medical assistance as above for vascular access and RSI.

Notes

Non-convulsive status may occur. It manifests as decreased conscious state with or without motor accompaniments. It may occur particularly in the Lennox-Gastaut syndrome, or in other children with developmental delay. Pyridoxine-dependent seizures should be considered in any infant under 18 months with recurrent or refractory afebrile seizures. A clinical trial of pyridoxine 100 mg i.v. is warranted. If it is going to be effective it will work within 10–60 minutes. If it is not effective in 10 minutes begin other standard anticonvulsants as above.

After the convulsion

First seizures, even if unprovoked, rarely require continuous anticonvulsant medication. Discuss with the Registrar or a Consultant. Parents should be warned that all children or adolescents who have had seizures should be supervised when bathing, swimming, or riding a bicycle on the road, and that children should avoid tree-climbing. Parents should be advised of first-aid measures should the seizure recur. In some centres, children with their first afebrile seizure are referred to the general pediatric outpatient clinic for follow up. If the child has not fully recovered, or there are concerns about the underlying etiology, he or she should be admitted to hospital.