Immediately following this episode, the parents took their son to the ED for evaluation. He was afebrile with normal vital signs. The physical examination, which included a neurological examination, was normal, and both parents noted that the child appeared to be completely back to his normal behavior. The patient’s past medical and surgical histories were unremarkable. His parents stated that he had not been on any medication and denied a family history of seizures.
Overview
Seizures, the most common pediatric neurological disorder, are a frequent presentation in the ED. It is estimated that between 4% and 10% of children will have at least one seizure before age 16 years.1,2 The highest incidence of occurrence is seen in children younger than age 3 years; this frequency decreases in older children.2
Seizures are the resulting clinical manifestations of abnormal excessive synchronized neuronal activity within the cerebral cortex. Most seizure activity is stereotypical and self-limited3 and can be divided into two main types: generalized and partial. Generalized seizures involve both cerebral hemispheres and impairment of consciousness, while partial (or focal) seizures involve a single area of one hemisphere. Generalized seizures are usually classified as convulsive or nonconvulsive and include the following subtypes: tonic-clonic, atonic, absence, and myoclonic. Partial seizures can be subdivided into simple or complex, depending on whether consciousness is impaired.
Initial Management
As with critically ill patients, the first and most vital step in managing a seizing patient is to assess the airway, breathing, and circulation. Although the airway is the most frequently compromised component, simple interventions such as jaw thrust, suctioning, or the insertion of an oral or nasopharyngeal airway are usually sufficient to maintain adequate airway. If intubation is required, use of a short-acting paralytic agent should be considered so as not to mask ongoing seizure activity.1 Patients actively seizing at presentation should be assumed to be in status epilepticus, which is defined as seizure activity lasting longer than 5 minutes or as repetitive seizure episodes without return of consciousness between episodes.
Treatment
The benzodiazepines are the first-line treatment for status epilepticus in pediatric patients. Although intravenous (IV) lorazepam has long been the standard for seizure termination, intramuscular midazolam has been shown to be as safe and effective in patients weighing more than 13 kg in whom IV access is either not available or is difficult to obtain.4
Many other forms of benzodiazepines exist for seizure cessation, such as diazepam gel, which is administered rectally. Intranasal and buccal administration of midazolam also has proved effective for pediatric seizure termination.5,6 Second-line therapies include IV fosphenytoin, levetiracetam, phenobarbital, and valproic acid.1,7,8 In infants, phenobarbital is usually the primary second-line therapy after benzodiazepines.
History and Behavioral Observation
Given both the significant number of causes of pediatric seizures and events that can mimic childhood seizure activity, obtaining a thorough history and detailed description of the seizure episode and any preceding events are essential. It is also important to note nonseizure-related activities unique to the pediatric population (eg, Moro reflex in young infants, back-arching with gastroesophageal reflux [Sandifer syndrome], breath-holding spells, daydreaming).
Differentiating normal movements from seizures can be particularly difficult with infants. For example, repetitive bicycling movements of the legs are a common sign of seizure activity in an infant but may be mistaken as normal by parents or inexperienced observers.
West Syndrome.
West syndrome (infantile spasms) is a rare severe seizure syndrome consisting of spasmodic flexural movements of the extremities and trunk that usually presents between ages 4 to 18 months. Subtle episodes can be misinterpreted as Moro reflex, the normal sudden extension of an infant’s extremities and arching of the back occurring from birth to approximately ages 3 to 5 months.9
Breath-holding.
An episode of loss of consciousness with associated cyanosis, pallor, rigidity, limpness, or even twitching that was immediately preceded by vigorous crying in a child ages 6 months to 5 years should prompt the physician to strongly consider a breath-holding spell.
Attention Deficit Disorder Versus Seizure Activity.
Children, especially those with attention deficit disorder, have a propensity for daydreaming. These children will often stare and not respond to voice at times; however, if these episodes are associated with facial movements or a sudden pause in activity (also known as behavior arrest), the possibility of absence or complex partial seizures should be suspected.2