Overview
Definition:
Home rescue plans for pediatric seizures involve providing immediate medication at home to stop prolonged or recurrent seizures, thus preventing complications and the need for emergency medical services
These plans are typically prescribed for children with epilepsy, recurrent febrile seizures, or those at risk of status epilepticus
The goal is to administer a benzodiazepine, such as diazepam or midazolam, to terminate the seizure quickly
This is crucial for preventing neuronal injury and improving patient outcomes
Careful instruction to caregivers is paramount for safe and effective use.
Epidemiology:
Epilepsy affects approximately 0.5-1% of children worldwide
Status epilepticus, defined as a seizure lasting longer than 5-30 minutes or recurrent seizures without recovery of consciousness, occurs in 20-40 per 100,000 children annually
Febrile seizures are common, affecting 2-5% of children between 6 months and 5 years of age, with a small percentage experiencing prolonged or recurrent seizures requiring rescue medication.
Clinical Significance:
Effective home rescue plans are vital for pediatric patients at risk of prolonged seizures
Timely administration of rescue medication can abort seizures, reduce the risk of status epilepticus, prevent potential neurodevelopmental deficits, and decrease hospital admissions and emergency room visits
This empowers caregivers and improves the quality of life for children with epilepsy and their families
For DNB and NEET SS preparation, understanding the indications, administration, and adverse effects of these medications is a high-yield area.
Age Considerations
Neonates:
Neonatal seizures are often subtle and require specific management
home rescue plans are rarely used due to the complexity and need for continuous monitoring.
Infants And Toddlers:
Rectal diazepam and buccal midazolam are commonly used for this age group
Caregiver training is essential due to the potential for aspiration and difficulty with oral administration
Febrile seizures are a significant indication here.
Older Children And Adolescents:
Intranasal midazolam and oral midazolam (though less rapid-acting) may be options
Careful assessment of seizure type and frequency is needed to determine the appropriate rescue medication and route.
Specific Formulations:
Availability of age-appropriate formulations (e.g., rectal suppositories, oral syringes, nasal sprays) is critical for safe and accurate dosing
Pediatric dosages are weight-based and must be precisely calculated.
Clinical Presentation
Seizure Types Requiring Rescue:
Prolonged seizures (typically >5 minutes)
Recurrent seizures within a short period without regaining consciousness
Clusters of seizures
Any seizure that causes concern for progression to status epilepticus.
Warning Signs For Caregivers:
Seizure lasting longer than usual
Child not waking up after a seizure
Child having difficulty breathing
Child turning blue or having irregular breathing
Repetitive jerking movements
Child appearing unresponsive.
Medication Administration Cue:
A specific duration of seizure (e.g., 5 minutes of continuous tonic-clonic activity) or a specific number of seizures occurring in a short interval triggers administration
This threshold must be clearly defined in the rescue plan.
Post Administration Monitoring:
Caregivers must monitor the child for seizure termination, respiratory depression, sedation, and any adverse reactions
Emergency services should be contacted if the seizure does not stop or if the child has breathing difficulties.
Diagnostic Approach
History Taking For Plan Creation:
Detailed seizure history: type, frequency, duration, triggers, postictal state, response to previous treatments
Child's overall health status: comorbidities, allergies, current medications
Family history of epilepsy or sudden unexpected death in epilepsy (SUDEP).
Physical Examination For Baseline:
Complete neurological examination to assess for underlying neurological deficits
Assessment of vital signs
Examination for any signs of trauma or injury related to seizures.
Investigations Confirming Epilepsy:
EEG: to confirm epileptiform activity and characterize seizure types
MRI Brain: to identify structural causes of epilepsy (e.g., tumors, cortical dysplasia)
Genetic testing: for specific epilepsy syndromes
Blood tests: to rule out metabolic causes.
Determining Need For Rescue Plan:
The decision is based on seizure frequency, duration, type, and the child's risk of developing status epilepticus
Consultation with a pediatric neurologist is essential to establish when and how to use rescue medication.
Management
Pharmacological Management Diazepam:
Rectal Diazepam: Dosage is typically 0.3-0.5 mg/kg per dose, maximum 10-20 mg depending on age and weight
Administered into the rectum
Onset of action is 2-10 minutes
Can be repeated once after 4-10 hours if needed, but this should ideally be under medical guidance.
Pharmacological Management Midazolam:
Buccal Midazolam: Dosage is 0.1-0.3 mg/kg per dose, maximum 10 mg
Administered into the buccal pouch between the cheek and gum
Rapid absorption, onset of action within 3-5 minutes
Intranasal Midazolam: Dosage is typically 0.1-0.2 mg/kg, maximum 10 mg
Administered into the nasal cavity using a mucosal atomization device
Rapid onset of action (1-3 minutes).
Non Pharmacological Interventions:
Securing the airway: turning the child onto their side to prevent aspiration
Loosening tight clothing
Avoiding restraint
Ensuring safety: removing potentially harmful objects from the vicinity
Never put anything in the child's mouth.
Emergency Medical Services Notification:
Always call emergency services (e.g., 108/112 in India) if the seizure lasts longer than the predetermined time (usually 5 minutes), does not stop after the first dose of rescue medication, or if the child has breathing difficulties or remains unresponsive.
Documentation And Follow Up:
Caregivers must document the time, dose, and route of rescue medication administered, and the child's response
A follow-up appointment with the neurologist is crucial to review the event and adjust the management plan.
Complications
Medication Side Effects:
Sedation or drowsiness
Respiratory depression, which can be severe and require airway support or ventilation
Hypotension
Paradoxical excitation (rare).
Treatment Failure:
Seizure not terminating after rescue medication, leading to status epilepticus
This may require further medical intervention, often in a hospital setting.
Adverse Events From Administration:
Injury to the nasal mucosa or rectal lining
Inadequate absorption due to improper administration technique
Aspiration if the child is not positioned correctly.
Prevention Strategies:
Precise dosing and adherence to administration instructions
Proper positioning of the child during administration
Close monitoring of vital signs (respiratory rate, oxygen saturation, consciousness) after administration
Training caregivers thoroughly on the rescue plan and potential side effects.
Key Points
Exam Focus:
DNB/NEET SS exam focus includes recognizing indications for home rescue, differentiating between diazepam and midazolam properties (route, onset, duration), knowing pediatric dosages, and understanding contraindications and side effects
Management of status epilepticus, including initial steps and escalations, is also critical.
Clinical Pearls:
Always emphasize caregiver education
demonstrate administration techniques
Have backup plans and ensure caregivers know when to call for help
Understand that home rescue is a bridge to definitive medical care, not a replacement for it
Titrate benzodiazepine use carefully, especially in neonates and infants, due to risk of respiratory depression.
Common Mistakes:
Incorrect dosing (under or overdosing)
Delayed administration of rescue medication
Inadequate caregiver training
Failure to contact emergency services when indicated
Administering medication to a child who is already awake and seizure-free
Using expired medication.