Febrile Seizures

Salient features.
Generalized, nonfocal seizure with an autosomal dominant transmission. Patients are usually 6 months to 5 years of age. Always self-limited, generally after 4 to 5 minutes but may last up to 15 minutes. Little postictal phase with prompt return of baseline mental status. If postictal, drowsy, or more than one seizure, see "grand mal" below. 2% to 5% will develop a chronic seizure disorder. 48% under 15 months of age will have a recurrent febrile seizure in the future as will 30% of those over 15 months, and 45% of those with a first-degree relative with history of febrile seizures. The American Academy of Pediatrics recommends against routine CT scanning, blood work, or EEG of patients with febrile seizures. Consider an LP for children under 18 months of age, and perform LP on those less than 12 months of age. Admission and work-up (CT/MRI or EEG) are indicated if there are focal signs or altered mental status since by definition these patients do not have simple febrile seizures. A metabolic workup and workup for meningitis should be done if appropriate. Finger-stick glucose should be done unless the patient is clinically normal.

Therapy.
No specific therapy for seizure (but see grand mal below if seizure is protracted); treat underlying cause of fever. Always evaluate patient clinically for meningitis, or other bacterial infection. It is not necessary to do a lumbar puncture in simple febrile seizures unless otherwise indicated. The American Academy of Pediatrics does not recommend seizure prophylaxis for patients with one or more febrile seizures. Long-term treatment. Chronic phenobarbital therapy prevents recurrence but may adversely affect learning. Valproic acid is as effective as phenobarbital with less behavioral effects (but with other drawbacks such as liver toxicity, etc.). Neither carbamazepine nor phenytoin are effective in preventing recurrent febrile seizures. Prevention. Diazepam 0.33 mg/kg PO Q8h starting at onset of fever and continuing for 24 hours after the fever reduced febrile seizures by 82% in those treated (intention to treat analysis equaled decrease of 44%). Oral diazepam may also be used. Acetaminophen and ibuprofen at the onset of a fever do not prevent febrile seizures.

Grand Mal Seizures and Status Epilepticus

Salient features.
Prolonged >15 minutes (if still seizing by time reach emergency department, by definition the patient has a grand mal seizure if transport time is included). May have focal signs or symptoms and a prolonged postictal state. May have the presence of a fever, but this is not a simple febrile seizure.

Etiology.
Metabolic. Check electrolytes, glucose, Ca++, Mg++, CBC. Toxins. Look for pinpoint pupils, dilated pupils, excess salivation, etc. (See section on overdosage and toxidromes). Get drug (prescription and illegal usage) history from family or drug screen. Hypoxia. Check respiratory status. Infection. If clinically indicated, perform LP. Do CT to rule out mass lesion (abscess) before doing LP in those with HIV (because of risk of toxoplasmosis) and those with localizing signs/symptoms but do not withhold antibiotics to do a CT. Space-occupying lesions (e.g., subdural hematoma, subarachnoid bleed, tumor). Evaluate with non-contrast CT. Poor compliance with medications. Target the work-up as indicated by history. It is not necessary to repeat all labs on a patient with a known seizure disorder with a simple exacerbation caused by poor compliance. Watch for a change in type or frequency of seizure to guide your work-up. Drug levels are indicated in any patient using antiepileptics, theophylline, or other seizure-inducing agent. Treatment. Because of the short half-life of benzodiazepines, patients will usually need a longer acting agent (e.g., phenytoin or phenobarbital) once the initial seizure resolves. Make sure to get levels in those already taking drugs. Be prepared to manage the airway: Seizures may cause hypoxia and treatment (benzodiazepines, phenobarbital) may cause apnea. Correct the underlying metabolic problem if one is present. STEP 1 MEDICATIONS FOR TREATING ONGOING SEIZURES Treatment of choice. Lorazepam (Ativan): Adults: 0.03 to 0.05 mg/kg IV (2 to 4 mg, 1-2 mg aliquots. Children: 0.05-0.1mg/kg IV maximum 4 mg) or double this rectally if IV access not possible. Advantage over diazepam is longer clinical half-life (hours of seizure

suppression versus minutes) with less respiratory depression and need for intubation. Alternative is diazepam (Valium) 0.1 to 0.3 mg/kg IV (5 to 10 mg in adult but may need 20 to 30 mg) or double this rectally if no IV access. If above does not work, try the medications below. STEP 2 MEDICATIONS FOR TREATING ONGOING SEIZURES Phenobarbital 15-20 mg/kg IV (maximum 25-30mg/kg) at 25 to 50 mg/min. May give IM. Respiratory depression is additive to that of benzodiazepines so patient may need intubation. Phenytoin (Dilantin) 15 mg/kg IV (1 mg/kg/min IV not to exceed 50 mg/min). Do not exceed 1 g in adults; mix with NS (50 ml/500 mg in adults); use in-line filter. Monitor for QT prolongation and stop infusion if increases by >50% (risk of torsades de pointes). An alternative to phenytoin is fosphenytoin (Cerebryx), a pro-drug that requires metabolism to the active form. There is little advantage to fosphenytoin; cardiotoxicity, local irritation, and so on are comparable. However, fosphenytoin is absorbed IM and can be administered rapidly. Fosphenytoin should be infused at >100 to 150 mg/min; subtherapeutic levels may occur if infused slowly. Therapeutic blood levels occur in 30 minutes if drug is rapidly infused. Dosing is the same as for phenytoin. The fosphenytoin dose is expressed as the phenytoin equivalent. Use in those with hepatic and renal disease is problematic because of their slower than normal metabolism to active drug and should be avoided. STEP 3 MEDICATIONS FOR TREATING ONGOING SEIZURES If above does not work (lidocaine and midazolam are not approved for these indications but are well tested): Lidocaine. 1.5 to 2 mg/kg IV over 2 minutes and repeated in 5 minutes if necessary with a drip at 3 to 4 mg/min. Same class of drugs as phenytoin and an excellent membrane stabilizer. Midazolam has been found to be useful in those unresponsive to full loading doses of lorazepam, phenobarbital, and phenytoin. Give midazolam bolus of 170 to 220 mg/kg followed by maximal infusion rates of 0.9 to 11 mg/kg/min. Can also give IM 0.07-0.3mg/kg. This may control seizures a bit faster but cannot titrate dose. Pyridoxine. A very rare patient (generally children or those with an isoniazid overdose) will be pyridoxine responsive, and if no other measures work, consider pyridoxine (vitamin B6) 100 mg IV. If suspect isoniazid overdose, give 4 g IV and then 1 g IV Q30 minutes until equal to

amount INH ingested; may give IV push if patient seizing. For children with INH overdose give 40 mg/kg IV. Most vi-tamin B6 responsive seizures occur in infants, but they have rarely been reported de novo in older children. STEP 4 MEDICATIONS FOR TREATING ONGOING SEIZURES Barbiturate coma. Call anesthesia department. Disposition: Patients with a first seizure should be considered for admission, as should those with a prolonged seizure (although admission is not mandatory if patient is back to baseline). A patient with a seizure disorder who has a breakthrough seizure need not be admitted. Approximately 50% of patients with one seizure will have another within 2 years if not treated long term as will 24% of those treated. Whether or not to start anticonvulsants after a first seizure is controversial. An EEG should be performed 3 weeks after the initial seizure (it will be abnormal immediately after a seizure and therefore does not give you any information on an underlying seizure focus). Neonatal Seizures May be atypical in physical presentation because of CNS immaturity. Grand mal may present with sequential clonic-tonic movements of extremities or only focal symptoms. Autonomic seizures noted by changes in respirations, heart rate, and pupils. Myoclonic seizures. Single clonic motions throughout day. It is important to pursue a cause, since frequently there is a specific treatment available. In ED, check electrolytes, calcium, glucose, magnesium, CBC, blood culture, and LP. EEG, CT, skull radiograph, long bone radiograph, as indicated. Bilirubin, ABG, urine amino acids as indicated. Treatment for neonatal seizures in this order and in absence of known correctable cause. Glucose 2 ml/kg of D25 Pyridoxine (vitamin B6) 50-100mg IV push Calcium gluconate (10%)- 30 to 60 mg/kg (1-2 ml/kg of 10% solution, maximum 10ml), slow IV on monitor. Magnesium sulfate 50% solution, 0.2 ml/kg IM or IV Phenobarbital. Premature infant 10 to 20 mg/kg IM or IV; term infant 10 to 15 mg/kg IM or IV. Infuse no faster than 30 mg/min. Phenytoin 10 to 15 mg/kg IV. Infuse no faster than 1 mg/kg/min. Lorazepam 0.05 to 0.15 mg/kg IV. Diazepam 0.2 mg/kg repeat twice. Maximum dose 5 mg age <5 years, 10 mg if age :10 years. Diazepam and lorazepam will increase hyperbilirubinemia by uncoupling

albumin-bilirubin complex. Therefore be careful in children with jaundice.