Pediatric Seizure and

Status Epilepticus Management in the

Emergency Setting
Edward P. Sloan, MD, MPH
Associate Professor
Department of Emergency Medicine
University of Illinois
Chicago, IL

Case
A 7-year old boy presents to the ED with a history of
staring spells, some shaking movements, and
headache over the past day. He has no history of
seizures or epilepsy. In the ED, he has three episodes
of tachycardia, staring and confusion that last several
minutes and resolve without therapy. He then has a
similar episode associated with diaphoresis and
urinary incontinence. His most likely diagnosis is:

Edward Sloan, MD, MPH

Most likely diagnosis:

A.
B.
C.
D.
E.

Absence status epilepticus

Complex partial status epilepticus
Benign childhood epilepsy
Lennox-Gastaut syndrome
Generalized convulsive status
epilepticus
Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Assuming that the above episodes in the 7-year

old represent repeated seizures, all of the
following are acceptable initial therapies except:
A.
B.
C.
D.
E.

Rectal diazepam
Rectal diazepam gel
IM midazolam
IV lorazepam
IV phenobarbital
Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Case
A 13-year old female presents at mid-morning to the ED
with a one-day history of a frontal headache, consistent
with prior migraines, that was relieved with ibuprofen.
She also was noted by family members to be restless in
bed, and was noted to thrash about for a brief period of
time. The family denied that this was a generalized
seizure, and denied any history of epilepsy, trauma,
drug ingestion, or similar episodes. The patient has a
similar episode in the ED, and then has a generalized
seizure.
Edward Sloan, MD, MPH

Most likely diagnosis:

A. Primary generalized seizure
B. Absence seizure
C. Complex partial seizure with
secondary generalization
D. Juvenile myclonic epilepsy
E. Non-convulsive status epilepticus
Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Case
A 21-year old male college student presents
in the early morning to the ED with a oneday history of having a generalized seizure
upon awakening. The patient had been
partying after final exams, and had not
been getting much sleep for several days.
Over the phone, his mom noted that he had
a history of staring spells as a child.
Edward Sloan, MD, MPH

Most likely diagnosis:

A. Primary generalized seizure
B. Absence seizure
C. Complex partial seizure with
secondary generalization
D. Juvenile myoclonic epilepsy
E. Non-convulsive status epilepticus

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

The above 21-year old patient had

two seizures in the ED which were
controlled with lorazepam. If a
load of a longer acting AED was to
be given in the ED in order to
prevent status epilepticus, what
would be the optimal drug to
administer?
Edward Sloan, MD, MPH

Most optimal drug:

A.
B.
C.
D.
E.

IV midazolam
IV phenytoin
IV fosphenytoin
IV valproate
IV phenobarbital

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

What is the optimal loading dose of IV

valproate in patients at risk for SE?
A.
B.
C.
D.

1-5 mg/kg
10-15 mg/kg
20-30 mg/kg
90-100 mg/kg

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

If an IV valproate load of 25 mg/kg were

given to this patient, what would be the
expected valproate level once the
infusion had ended?

Edward Sloan, MD, MPH

Expected IV Valproate level?

A.
B.
C.
D.
E.

25 mg/L
50 mg/L
75 mg/L
100 mg/L
125 mg/L
Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

If this patient were to develop

status epilepticus, what is the
fastest time of infusion possible
for a loading valproate infusion of
2500 mg (25 mg/kg x 100 kg)?

Edward Sloan, MD, MPH

Fastest Infusion Time Possible?

A. 4 minutes (6 mg/kg/minute)
B. 8 minutes (3 mg/kg/minute)
C. 24 minutes (1 mg/kg/minute)
D. 2 minutes (0.3 mg/kg/minute)
E. 216 minutes (0.1 mg/kg/minute)
Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Overview
Global Objectives

Learn more about pediatric seizures

Focus on peds sz etiologies
Increase awareness of Rx options
Enhance our ED management
Improve patient care & outcomes
Maximize MD & patient satisfaction
Edward Sloan, MD, MPH

Overview
Pediatric Sz Epidemiology
Common EMS & ED problem
Szs are up to 6% of EMS encounters
Up to 1% of all ED visits are peds sz
Peds febrile: 1 in 125 visits (0.8%)
Peds afebrile: 1 in 500 visits (0.2%)

Edward Sloan, MD, MPH

Overview
Pediatric Sz Epidemiology

2-5% have a febrile seizure

1% have an afebrile sz by age 14
Highest afebrile sz rate before age 3
0.4-0.8% of children develop epilepsy
SE most common before age 1

Edward Sloan, MD, MPH

Overview
Pediatric Sz Epidemiology
Mean age 3.2 yrs, median age 1 year
61% by age 3
Etiology age dependent
25% is febrile SE
Before age 1, 75% due to acute insult
Epilepsy, fever, CNS infection common
Edward Sloan, MD, MPH

Pediatric Sz Etiologies
Meningitis

Altered mental status universal

Seizures in 23% of meningitis cases
Complex & GTC seizures common
Simple seizures rarely seen
HIB vaccine makes this etiology rare

Edward Sloan, MD, MPH

Hyponatremia

Causes long duration szs and SE

Infants < 6 months old, no clear etiol
Too much water in formula
Hypothermia (Temp < 36.5 degrees)

Edward Sloan, MD, MPH

Cocaine Toxicity

Consider in new onset seizures

Crack cocaine rocks ingested
Especially when no other etiology
Common in urban EDs

Edward Sloan, MD, MPH

Pediatric Seizures
Seizure Outcome
Immature CNS, myelinization
More prone to seizures
More resistant to consequences

Continuous seizures less toxic

SE carries a low mortality (3-6%)

Edward Sloan, MD, MPH

Pediatric Seizures
SE Outcome
Based on CNS status prior to SE
Normal CNS, 64% remain intact
Mortality related to two factors:
Acute neurologic insult
Chronic CNS condition

Edward Sloan, MD, MPH

Pediatric Seizures
Seizure Type Classification
Generalized
Involves both cerebral hemispheres
Convulsive: tonic-clonic seizures
Non-convulsive: absence seizures

Partial
Involves one cerebral hemisphere
Simple: no impaired consciousness
Complex: impaired consciousness
Edward Sloan, MD, MPH

Seizure Classification
Generalized Seizures
Convulsive seizures
Tonic sz: sustained contractions
Clonic sz: rhythmic flexor spasms
Tonic-clonic sz: combined movements

Non-convulsive
Simple absence: impaired consciousness
Complex absence: brief motor mvmts
Edward Sloan, MD, MPH

Seizure Classification
Partial Seizures
Simple seizures (no LOC)
Focal motor (Jacksonian)
Sensory or somatosensory
Autonomic
Psychic

Complex (impaired consciousness)

Involves some cognitive, affective sx
Temporal lobe, psychomotor seizures
Edward Sloan, MD, MPH

Pediatric Seizures
Other Generalized Sz Types

Neonatal seizures
Benign childhood epilepsy (Rolandic)
Infantile spasms (West syndrome)
Lennox-Gastaut syndrome
Atonic seizures
Febrile seizures
Edward Sloan, MD, MPH

Pediatric Seizures
Status Epilepticus Types
Convulsive SE: tonic-clonic sz
Non-convulsive SE: no tonic-clonic sz
Absence SE
Complex partial SE

Subtle SE: prolonged convulsive SE

Worst prognosis, mortality > 30%
Persistent coma, focal motor mvmts only
Edward Sloan, MD, MPH

Specific Seizure Types

Febrile Seizures

Age: 6 months to 5 years

Related to rapid rise in temperature
Brief, self-limited generalized sz
Complex: Focal, > 10-15 min, flurry
25% recurrence, esp if in child < 1 yr old
Risk of epilepsy not significantly greater

Edward Sloan, MD, MPH

Specific Seizure Types

Juvenile Myoclonic Epilepsy

Common in teens, young adults

Etiology of generalized TC seizures
History of staring spells
History of AM clumsiness, myoclonus
Sleep deprivation, EtOH precipitants
Phenytoin: worse myoclonus, absence sz

Edward Sloan, MD, MPH

Specific Seizure Types

Generalized Convulsive SE

Seizure lasting greater than 5-10 min

Refractory to initial benzo therapy
Flurry of seizures and coma
CNS injury likely after 30-40 minutes
Glutamate, cell death, tissue necrosis
Injury even if systemic sx controlled
Edward Sloan, MD, MPH

Specific Seizure Types

Non-Convulsive SE
No generalized tonic-clonic sz
Absence SE
Complex partial SE

No frank coma
More common in children
Not always due to co-morbidity
Mortality ?? Not as high as in GCSE
Edward Sloan, MD, MPH

Seizure Therapy
Generalized Seizure Protocol
Benzodiazepines
PR diazepam, IM midazolam, IV lorazepam

Phenytoins
Fosphenytoin can be given IV or IM

Phenobarbital or valproate
Less sedation with valproate

Propofol or midazolam infusions

EEG monitoring, BP support key
Edward Sloan, MD, MPH

Seizure Therapy
Ongoing Therapies
Absence:
Atonic:
Myclonic:
Partial:
Generalized:

ethosuximide, valproate
valproate, clonazepam,
ethosuximide
valproate, clonazepam
carbamazepine,
phenytoin, valproate
carbamazepine,
phenytoin, phenobarb,
primidone, valproate
Edward Sloan, MD, MPH

Case Presentation
ED Pediatric Seizure Cases
Pediatric complex partial SE
New onset SE in an adolescent
New onset sz in a college student

Edward Sloan, MD, MPH

Pediatric SE
Hx

7 year old male

Seizure-like activity?
Patient with staring spells
Some headache and shaking movement,
esp of hands
Frontal headache, vomiting
Edward Sloan, MD, MPH

Pediatric SE
Hx (cont.)
Seen at 2130, 2230 sign-out
AMS, r/o seizure disorder
Once all of the labs are back, he should
be OK to go home

Edward Sloan, MD, MPH

Pediatric SE
Px

98.7, 98/60 72 20
Well-hydrated
CV, lung exams normal
Neuro exam intact

Edward Sloan, MD, MPH

Pediatric SE
Clinical Course

0220 episode
Tachycardia, BP OK, airway OK
Confused, staring off into space
Episode lasted < 5 minutes
Resolved without any Rx

Edward Sloan, MD, MPH

Pediatric SE
Clinical Course (cont.)

Three more episodes over 40

Similar autonomic symptoms
Some non-purposeful ext mvmts
Diaphoresis, urinary incontinence
Remained somnolent between episodes

Edward Sloan, MD, MPH

Pediatric SE
Dx

Repetitive episodes with AMS

Autonomic symptoms noted
Non-purposeful mvmts noted
Rule out complex partial status
epilepticus (CPSE)

Edward Sloan, MD, MPH

Pediatric SE
Rx

IV lorazepam
IV valproate
Transfer to Childrens
ICU observation
Uncomplicated course

Edward Sloan, MD, MPH

Adolescent SE
Hx

13 year old female

Frontal HA and prior migraines
HA relieved with ibuprofen
AMS in AM, with ?? motor activity
Restless at home, thrashing on bed
No other systemic sx or recent illness
Edward Sloan, MD, MPH

Adolescent SE
Px

Vitals OK, afebrile

Alert, O x 3, NAD
Head/Neck OK
Chest/cor/abd OK
Neuro: No focal deficit. MS OK

Edward Sloan, MD, MPH

Adolescent SE
Clinical Course

Labs, tox screen neg

CT negative
Neuro consult: EEG and then D/C
Dx: AMS, r/o Seizure; migraine HA
While EEG applied, pt with AMS
Agitation, thrashing on cart
Edward Sloan, MD, MPH

Adolescent SE
Clinical Course (cont.)

During EEG, pt with R face focal sz

Leftward gaze noted
Seizure then generalized
Meds were given
Seizure terminated

Edward Sloan, MD, MPH

Adolescent SE
Clinical Course (cont.)

Seizure terminated with Rx

Pt stabilized, still somnulent
ALS transfer team to Childrens
Pt with resolving AMS at time of D.C

Edward Sloan, MD, MPH

Adolescent SE
Dx
New onset SE
Complex partial seizures with
generalized seizure / SE
Hx migraine headaches

Edward Sloan, MD, MPH

Adolescent SE
Rx
Lorazepam to Rx the acute sz
2 mg IVP x 2

Valproate for ongoing protection

25 mg/kg load administered
Infused over 20 minutes

PRN meds during transfer

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Edward Sloan, MD, MPH

Juvenile Myoclonic Sz
Hx

21 year old college student

No prior neuro history
Final exams, sleepless
Great party after the last exam
Pt with single generalized sz
Seizure upon awakening
Edward Sloan, MD, MPH

Juvenile Myoclonic Sz
Px

Vitals OK
Neuro: slightly post-ictal
Exam otherwise normal
Patient has a 2nd seizure in the ED

Edward Sloan, MD, MPH

Juvenile Myoclonic Sz
Dx
Juvenile myoclonic epilepsy
Related to sleep deprivation, alcohol
consumption
Occurs upon awakening
Responds best to valproate
Phenytoin may exacerbate sx
Edward Sloan, MD, MPH

Juvenile Myoclonic Sz
Rx

Benzodiazepines to Rx the acute sz

Ongoing protection an issue
Valproate is likely the drug of choice
Phenytoin may not be optimal
Avoid status epilepticus

Edward Sloan, MD, MPH

Conclusions
Clinical Pearls
Acute, repetitive spells = sz
Ongoing altered mental status =
complex partial SE
Treat acute szs with lorazepam
Valproate is the etiology-specific
ongoing Rx in many young people
Know the specific JME clinical setting
Edward Sloan, MD, MPH

Conclusions
Learning Points

Acute, repetitive spells = sz

Multiple meds and routes possible
Opportunity to optimize Rx
Acute seizure control: IV benzos
2nd line Rx may differ based on Dx
Ongoing needs may influence 2nd Rx
EEG may be of use in ED SE
Edward Sloan, MD, MPH

Recommendations
Management Implications

Educate about sz etiologies

Make multiple drugs available
Alternate routes should be used
A protocol should exist
Utilize EEG when necessary
Be aware of optimal Rx at disposition
Edward Sloan, MD, MPH