Overview
Definition:
A seizure is a transient occurrence of signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain
In pediatrics, seizures are common and can range from benign febrile seizures to life-threatening status epilepticus
Observation is critical to characterize the seizure type, while timely admission and appropriate rescue medication are paramount for patient safety and effective management.
Epidemiology:
Seizures affect approximately 5-10% of children by age 15, with febrile seizures being the most common type
Epilepsy, defined as recurrent unprovoked seizures, affects about 1% of children
The incidence of status epilepticus in children varies but is a significant cause of emergency department visits.
Clinical Significance:
Understanding seizure observation, admission, and rescue medication is vital for pediatric residents and DNB/NEET SS candidates to ensure prompt diagnosis, appropriate management, prevention of complications like brain injury and SUDEP, and accurate risk stratification
This knowledge directly impacts patient outcomes and is frequently tested in examinations.
Clinical Presentation
Symptoms:
Abrupt, involuntary movements of limbs or body
Altered consciousness, staring spells, or unresponsiveness
Autonomic changes: pallor, cyanosis, flushing, sweating, piloerection
Sensory disturbances: visual or auditory hallucinations, focal numbness
Behavioral changes: confusion, agitation, crying
Postictal confusion or lethargy.
Signs:
Tonic or clonic movements
Loss of consciousness
Pupillary changes
Motor arrest or automatisms
Vital sign abnormalities: tachycardia, hypertension, fever, respiratory distress
Focal neurological deficits during or after seizure.
Diagnostic Criteria:
No single set of diagnostic criteria for all seizure types
diagnosis is primarily clinical
For status epilepticus: prolonged seizure (generalized >5 min, focal >10 min) or recurrent seizures without recovery of consciousness between them
Febrile seizure criteria: convulsion in a child aged 6 months to 5 years with a temperature >38°C (100.4°F) not attributable to a CNS infection or metabolic derangement.
Diagnostic Approach
History Taking:
Detailed description of the event: onset, duration, character of movements, associated symptoms, loss of consciousness
Precipitating factors: fever, illness, trauma, sleep deprivation, medications
Past medical history: previous seizures, developmental milestones, birth history
Family history of seizures or epilepsy
Red flags: focal onset, prolonged duration, status epilepticus, associated neurological deficits, signs of CNS infection.
Physical Examination:
General appearance: signs of distress, postictal state
Neurological examination: assess mental status, cranial nerves, motor strength, sensation, reflexes, coordination
Examination for signs of trauma, infection (meningitis, encephalitis), metabolic derangements
Fundoscopy to rule out papilledema.
Investigations:
Laboratory tests: blood glucose (hypoglycemia is common), electrolytes (Na, Ca, Mg), complete blood count (infection), liver and renal function tests, toxicology screen if indicated
Lumbar puncture: if suspicion of CNS infection (meningitis, encephalitis)
Electroencephalogram (EEG): gold standard for diagnosing epilepsy and characterizing seizure types
may be normal between seizures
Neuroimaging: MRI brain is preferred over CT for evaluating structural lesions, especially in prolonged seizures or suspected focal epilepsy
CT may be useful for acute trauma or hemorrhage.
Differential Diagnosis:
Syncope, breath-holding spells, psychogenic non-epileptic seizures (PNES), movement disorders (e.g., tics, dystonia), migraine aura, transient ischemic attack (rare in children), sleep disorders (e.g., parasomnias), infantile colic, gastroesophageal reflux.
Management
Initial Management:
Ensure airway patency, breathing, and circulation (ABC)
Protect from injury
Monitor vital signs
Obtain IV access
Provide supplemental oxygen if hypoxic
Assess blood glucose and treat hypoglycemia immediately (IV dextrose).
Rescue Medication:
For active seizures or suspected status epilepticus: Benzodiazepines are first-line
Lorazepam (0.1 mg/kg IV/IM, max 4 mg per dose, repeat once after 5-10 min)
Diazepam (0.1-0.2 mg/kg IV, max 10 mg per dose, repeat once after 5-10 min
rectally: 0.5 mg/kg, max 10 mg)
Midazolam (IM: 0.1-0.2 mg/kg, max 10 mg
buccal: 0.1-0.3 mg/kg, max 10 mg)
If seizure persists after two doses of benzodiazepines, consider second-line agents: Phenobarbital (loading dose 15-20 mg/kg IV), Fosphenytoin or Phenytoin (loading dose 15-20 mg PE/kg IV), Levetiracetam (loading dose 20-60 mg/kg IV), Valproic acid (loading dose 20-40 mg/kg IV).
Admission Criteria:
Status epilepticus (>5 minutes generalized or >10 minutes focal)
Recurrent seizures within 24 hours
New onset seizure without clear precipitant (e.g., fever)
Focal neurological deficits
Signs of CNS infection
Electrolyte abnormalities
Suspected structural brain lesion
Neonatal seizures
Inability to ensure safety or adequate monitoring at home
First seizure in a child under 6 months of age
Concerns for underlying epilepsy diagnosis.
Supportive Care:
Continuous cardiorespiratory monitoring
Neurological status assessment
Maintaining hydration and nutrition
Seizure precautions
Education for parents/caregivers regarding seizure management, medication adherence, and safety measures
Follow-up EEG and neurological assessment to guide long-term antiepileptic drug (AED) therapy.
Complications
Early Complications:
Hypoxia, aspiration, physical trauma, hyperthermia, rhabdomyolysis, arrhythmias, cerebral edema, prolonged postictal state.
Late Complications:
Brain injury from prolonged seizure activity or underlying etiology
Development of chronic epilepsy
Cognitive and developmental impairments
Sudden Unexpected Death in Epilepsy (SUDEP).
Prevention Strategies:
Prompt recognition and aggressive treatment of active seizures
Timely administration of appropriate rescue medications
Effective management of underlying causes (e.g., fever, infection, metabolic derangements)
Adherence to prescribed AED regimens for children with epilepsy
Educating caregivers on seizure safety and emergency protocols.
Prognosis
Factors Affecting Prognosis:
Underlying etiology (structural, genetic, metabolic vs
isolated febrile seizure)
Age of onset
Seizure type and frequency
Response to treatment
Presence of neurological deficits
EEG findings
Degree of parental understanding and compliance.
Outcomes:
Many children with benign seizure types (e.g., simple febrile seizures) have excellent outcomes with no long-term sequelae
Children with epilepsy due to structural brain lesions or severe underlying conditions may have ongoing seizures and developmental challenges
Status epilepticus, especially if prolonged or inadequately treated, carries a risk of neurological damage and worse long-term outcomes.
Follow Up:
Regular follow-up with a pediatric neurologist is essential to monitor seizure control, adjust AEDs, assess development, and manage any complications
Duration of follow-up and need for long-term treatment depend on the etiology and seizure control
Discontinuation of AEDs may be considered after prolonged seizure freedom, typically 2-5 years, under medical supervision.
Key Points
Exam Focus:
Differentiate seizure types and identify triggers
Know first-line and second-line rescue medications with dosages (IV, IM, rectal, buccal)
Understand indications for admission and specific criteria for status epilepticus
Recognize urgent investigations needed in the acute setting
Differentiate febrile seizures from CNS infections.
Clinical Pearls:
Always check blood glucose immediately in a child with a new seizure
Benzodiazepines are your best friends for initial seizure control
If a child is having recurrent seizures and not improving, think about non-benzodiazepine agents like levetiracetam or valproate
Prompt and appropriate management of status epilepticus is critical to prevent secondary neuronal injury
Always document seizure semiology meticulously.
Common Mistakes:
Delayed administration of rescue medication
Inadequate dosing of rescue medications
Misinterpreting febrile seizures as simple and not investigating for CNS infection when indicated
Failure to consider underlying metabolic or electrolyte derangements
Discharging patients with prolonged seizures or concerning neurological findings without adequate workup or observation.