Is It All In Your Head?:Pediatric Seizure

Recognition & Management

Angie Bowen, RN, BSN, CPEN, NREMT-P ICEMSC Regional Coordinator/Trauma Coordinator

East Tennessee Children’s HospitalKnoxville, Tennessee

Why Seizures?

Common Concerns

Overall State Concerns

Assessment 39.8%Medication 35.2%

Airway Management 22.1%Report of Information 21.9%

Circulatory Management 16.5%Mode of Transport 10.6%

Refusal/NPC 3.1%

* Percentage mismatch: many calls had multiple issues

Common Concerns

East Tennessee Children’s HospitalMarch 2012-March 2013

3192 ambulance/air transports1688 were emergency traffic

• 63 ConcernsEMS 39%, Hospitals 56%, Other 5%

• EMS:Assessment 49% (unrecognized seizures #1)Medication 30% (incorrect dose or wrong/no med)Airway Management 22% (no O2, BVM needed)

Seizure Disorders

• Periods of abnormal electrical discharges in the brain that cause involuntary movement, and behavior and sensory alterations.

• Epilepsy is a chronic disorder characterized by recurrent, unprovoked seizures secondary to a neurologic disorder. Approximately 20% of all cases develop by 5 years of age.

Status Epilepticus

• Continuous seizure activity lasting longer than 5 minutes, or at least 2 seizures without return to baseline level of consciousness between

• Most frequently seen in young children and the elderly

• Mortality rate ~3% in pediatrics

Seizures• Febrile illness• Seizure disorder• Infections• Metabolic disturbances (Hypoglycemia)• Toxins• Trauma• Noncompliance with medications• VP shunt malfunction• Emotional Stress/Anxiety/Fatigue

Ventriculoperitoneal Shunts

• Drains excess CSF

• Prevents buildup of excessive CSF and increased ICP

Febrile Seizures

• Transient disorder of childhood• Affects 3% of all children• 2x more frequent in males• Usually occur between ages 6 months-3 years;

rare after age 5• Rapidly rising or falling temperature• Generalized tonic-clonic activity; focal is rare• Seizure usually self-limited & with short postictal

period• Remember: fever may trigger a seizure in patients

with epilepsy

Febrile Seizure Management

• 95%-98% of children with febrile seizures will not have epilepsy or neurologic damage

• Evaluate history (episodic and family)• Seizure control if ongoing• Avoid tepid baths—usually ineffective• Vigorous use of antipyretics to reduce fever • Protect child from injury during seizure

Myoclonic Seizures• Myoclonus is a brief and rapid twitching of a muscle or

muscle groups. Myoclonus cannot be stopped or controlled at will.

• There are different types of myoclonus. Some occur normally (hiccups, occasional movement while falling asleep, “shuddering attacks” in babies). Other types are pathological, or abnormal (brain lesions, medication side effects and epilepsy).

• Contractions are called positive myoclonus; relaxations are called negative myoclonus.

Myoclonic Seizures• Light, sound, touch or movement may be triggers, or it

may happen for no apparent reason. • There may be one or a series of twitches. • Sometimes the jerking occurs in a pattern. • Myoclonus can become so severe that it interferes with

eating, speaking, or walking.• In juvenile myoclonic epilepsy, seizures usually involve

the neck, shoulders, and upper arms. These seizures typically occur shortly after waking up. They normally begin between puberty and early adulthood.

Neonatal Seizures• Neonatal seizures occur in a baby who is less than 28

days old. It is estimated that neonatal seizures occur in one in every 350 babies.

• The baby will not necessarily go on to have epilepsy later in life, although the chances are significantly increased (20-30%).

• Risk is higher if baby is premature or low birth weight.

Neonatal Seizures• Seizures in a newborn are often short and subtle• Can include any or all of the following:

– Repetitive facial movements, including sucking, chewing, or eye movements; staring

– Bicycling or pedaling movements of the legs– Clonic seizures (rhythmic jerking movements); tonic

seizures (stiffening or tightening of muscle groups); the head or eyes may turn to one side, or the baby may bend or stretch one or more arms or legs

**If you can stop the event by changing the position of the baby’s limbs, it is not a seizure.

Absence Seizures• Formerly called “petit mal” or “lapses”• Brief loss of consciousness with no warning or aura• Minimal or no change in muscle tone• Almost always appear in childhood (4-12)• Sudden onset of up to 20+ events per day of 5-10

seconds duration • Motor: lip smacking, twitching of eyes, face, slight hand

movements. May drop object, but child rarely falls. No incontinence.

• Often misdiagnosed as inattention/daydreaming, ADD/ADHD

Infantile Spasms• Onset in first 6-8 months of life, 2x more

frequent in males. Poor prognosis (mental and developmental)

• Usually associated with some degree of mental retardation. Often associated with cerebral anomalies (microcephaly), anoxic brain injury, phenylketonuria (PKU)

• Head and neck flex forward, knees drawn up (jackknife position). May also have tonic posture or other abnormal movements.

• May or may not have LOC. No postictal drowsiness

Seizures

Seizure Interventions:• Oxygen, airway adjuncts• Administer anticonvulsant

medications• Check glucose & treat

hypoglycemia (*hyperglycemia)• Initiate seizure precautions• Continuous evaluation of

neurologic status and vital signs• Seizure description

Anticonvulsants• Diazepam (Valium) 0.1 mg/kg IV/IO, 0.5 mg/kg PR

– Rx of choice for status epilepticus– Rectal gel for home management (Diastat)– Onset 3-10 minutes; short duration (minutes)

• Lorazepam (Ativan) 0.1 mg/kg IV/IO– May be preferable to diazepam because of longer duration

of action & less respiratory distress in children < 2 yrs

• Midazolam (Versed) 0.1 mg/kg IV/IO/IN– May use intranasal route– Onset 3-5 minutes

Pediatric Seizures

• Nomenclature changes frequently• Describe what you see• Distinguish between:

- Focal / Generalized- Fever / No Fever- Seizure → Trauma or

Trauma → Seizure• Compare with previous seizures

Lessons Learned

Questions

eps411.com

Contact Information

Angie Bowen(865) 541-8523

abowen@etch.com

www.etch.com

Emily is a 3 year old who was diagnosed with anear infection yesterday by her PMD. UponEMS arrival at a local preschool, you find Emilyexhibiting clonic-tonic seizure activity that hasbeen going on about 10 minutesper the caregivers. Emily has no history of seizures.

Emily

Upon assessment, you notice Emily has gurglingrespirations and a dusky appearance. Whataction(s) should be performed first?

1. Bag-valve-mask ventilation2. Suction, oxygen and nasal airway3. IV access and benzodiazepines4. Suction, oxygen and oral airway

Emily

While you complete the appropriate airwayinterventions, your partner places an IV inEmily’s left hand. A normal saline bolus of20 ml/kg is initiated. Emily continues to haveseizure activity.

Emily

Emily

Which is the most appropriate medication anddosage for Emily’s seizure?

1. Valium 0.2 mg/kg PR every 15 minutes2. Versed 0.05 mg/kg IV every 10 minutes3. Valium 0.4 mg/kg IN every 5 minutes4. Ativan 0.1 mg/kg IV every 10 minutes5. Versed 1 mg/ kg IV every 5 minutes6. Ativan 1 mg/kg IN every 5 minutes

After benzodiazepine administration, you noticeEmily’s respiratory rate and pulse ox begin to fall. You are less than 5 minutes from yourdestination hospital.

Emily

Emily

What action(s) should you take next?

1. Tell your partner to let the ED know that you now have an airway situation with this patient.

2. Place a towel roll under Emily’s shoulders to optimize positioning.

3. Begin bag-valve-mask ventilations4. All of the above

Emily required assisted ventilations for 10minutes after arrival in the ED, but was soonable to control her own airway. She wasadmitted for observation, exhibited no further seizure activity and was discharged home the next day.

Emily

Tennessee Regions