Seizures

[tchristifulli]

I recently attended a pediatric emergency class through UW Madison. They talked about pediatric seizures and how they won't intervene with drugs unless the seizure goes longer than 5 minutes. That seems like a long time. They just stress keeping airway patent. Has anyone else heared of this?

 

[TheLocalMedic]

Yes, often treating the underlying cause of a seizure (especially febrile) is better stopping it with medication. And as long as the patient has a patent airway and is moving some air, it is better to wait it out for a little while to let it stop of its own accord.

 

[Christopher]

I recently attended a pediatric emergency class through UW Madison. They talked about pediatric seizures and how they won't intervene with drugs unless the seizure goes longer than 5 minutes. That seems like a long time. They just stress keeping airway patent. Has anyone else heared of this?

Our last pedi neuro lecture was similar, but we were told 2-3 minutes. I'm sure there is no prospectively defined interval. Instead you're given some period of time to "wait it out" so that we're not pushing drugs when unnecessary.

 

[chaz90]

Same really applies to adult patients with a seizure disorder. As EMS, we have a built in time delay from someone witnessing the seizure->calling 911->dispatch->response time->patient contact. If the patient is still actively seizing at that point, it's probably time we step in and stop it. An ED doc has told me (obviously somewhat tongue in cheek) that his first action when someone seizes in the ED is to step out of the room and go get a cup of coffee. If the patient is still seizing when he returns, he then orders pharmacological interventions.

 

[medicsb]

Most seizures self-terminate within 5 minutes. I'm not sure if there is any good evidence to support that, but it is generally accepted now that if the seizure doesn't end by the 5 minute mark, it probably won't without intervention.

 

[Christopher]

Most seizures self-terminate within 5 minutes. I'm not sure if there is any good evidence to support that, but it is generally accepted now that if the seizure doesn't end by the 5 minute mark, it probably won't without intervention.

The current definitions I've seen in the literature (Lowenstein Epilepsia, 40(1):120-122, 1999; Abend Pedi Emerg Care, 24(10):705-721, 2008):

<5 min is "Single Seizure" or "Incipient Status Epilepticus"
5-30 mins is "Early status epilepticus"
30+ mins is "Established status epilepticus"

"Refractory" used to be based on time limits, but is now "not terminated by 2 meds".

Apparently in the 90's they added "Malignant" to the list, which means the addition of anesthetics in addition to benzos and antiepileptics is unsuccessful too.

 

[mycrofft]

And how much effective respiration is taking place during a grand mal seizure? (Time is tissue...).

However, yeah, kids can snap out of it quickly once you figure out what's causing it and then that prime cause stops harming them.

And the number one cause of seizures in small children is...

 

[tchristifulli]

Febrile seizures

 

[mycrofft]

Winner gets a chicken dinner.
But don't ignore chance of drugs/poison, closed head injury.

 

[TheLocalMedic]

And how much effective respiration is taking place during a grand mal seizure? (Time is tissue...).

However, yeah, kids can snap out of it quickly once you figure out what's causing it and then that prime cause stops harming them.

And the number one cause of seizures in small children is...

In a tonic-clonic seizure (grand mal), there is general stiffening during the tonic phase where respiration may decrease or even stop, but it resumes during the clonic phase, although it might be irregular. However, the tonic phase usually doesn't last much longer than a minute.

So there is respiration taking place during (most) seizures. Maintaining a patent airway is paramount, but it is uncommon for breathing to completely cease throughout the seizure. By all means, give supplemental oxygen though.

 

[Household6]

The current definitions I've seen in the literature (Lowenstein Epilepsia, 40(1):120-122, 1999; Abend Pedi Emerg Care, 24(10):705-721, 2008):

<5 min is "Single Seizure" or "Incipient Status Epilepticus"
5-30 mins is "Early status epilepticus"
30+ mins is "Established status epilepticus"

"Refractory" used to be based on time limits, but is now "not terminated by 2 meds".

Apparently in the 90's they added "Malignant" to the list, which means the addition of anesthetics in addition to benzos and antiepileptics is unsuccessful too.

30 minutes to status epilepticus? I thought it was just two or more without regaining consciousness..

I do wonder if I, personally, lack a sense of freak-out emergency with febrile seizures that are caused by common childhood illnesses. Say, a 2yo with a fever of 104 from an ear infection.. "Oh, she's got a fever and oh look, now she's seizing. Put her in a cool bath, give her Tylenol when she comes to."

It just always seemed to me that a febrile seizure means the brain is working properly to protect itself.

ETA: Don't get me wrong, I know it can be terrifying to the caregiver. But when a 9months to 5yo is obviously running a high fever, is on ABs for an infection, and the caregiver has been withholding NSAIDs and Tylenol for whatever reason, the cause is fairly cut and dry. I mean to me, a febrile seizure caused by a fever is fairly avoidable, and it's just not a huge deal..

Maybe it's because I have a sister with epilepsy and it's just not a big deal anymore. "Oh look, sister is in her auric phase, let's get her glasses off and move her off the couch in case she pees her pants."

 

[TheLocalMedic]

The definition of status epilepticus seems to vary both by region and whether they are in or out of a hospital. Here (for EMS) they determine it by time (a few minutes witnessed by a medic) or two or more without regaining consciousness. However in the hospital it's time (>20 mins) or inability to stop it with two rounds of meds. I haven't heard about the "malignant" definition before, but I'll look into it.

 

[Carlos Danger]

An ED doc has told me (obviously somewhat tongue in cheek) that his first action when someone seizes in the ED is to step out of the room and go get a cup of coffee. If the patient is still seizing when he returns, he then orders pharmacological interventions.

The overall context is a important, too, of course.

A person with a known epileptic history having a seizure is very different than a person with no seizure history who recently banged their head or started a new medication or "experimented" with a new pharmaceutical....

 

[zeekman]

What other things can cause a seizure in a toddler?

 

[Christopher]

What other things can cause a seizure in a toddler?

Epilepsy (softball), febrile, hypoxia (foreign body comes to mind, although consider any cause), trauma/ICP changes, hypoglycemia, hyperglycemia (DKA/HHNS), cardiac arrhythmia w/ associated hypotension, poisoning/intoxication, metabolic, infection, neoplasms, arteriovenous malformations, CVA, genetic/congenital brain malformation...hmm the list could go on and on!

 

[WTEngel]

I do wonder if I, personally, lack a sense of freak-out emergency with febrile seizures that are caused by common childhood illnesses. Say, a 2yo with a fever of 104 from an ear infection.. "Oh, she's got a fever and oh look, now she's seizing. Put her in a cool bath, give her Tylenol

There is currently no evidence that antipyretics prevent febrile seizure. In fact, even though the exact cause is not known, most of the experts agree that febrile seizure is precipitated by sharp rise in temperature ("spiking" a fever). In my experience, fever spiking increases with aggressive of antipyretics by lay caregivers, because it is difficult to manage a dosing regimen that eliminates temperature fluctuations in children. Placing a child in a cool bath may be very bad advice actually, as this too, will increase the dramatic fluctuation of temperature that is linked with incidence of febrile seizure.

use when she comes to."

It just always seemed to me that a febrile seizure means the brain is working properly to protect itself.

There seems to be a genetic predisposition towards having febrile seizures. I wouldn't say this qualifies as the brain working properly and having a protective effect for the patient. While the vast majority of patients who have febrile seizures have no long lasting ill effects, I would be cautious about being so nonchalant about the matter.

ETA: Don't get me wrong, I know it can be terrifying to the caregiver. But when a 9months to 5yo is obviously running a high fever, is on ABs for an infection, and the caregiver has been withholding NSAIDs and Tylenol for whatever reason

many pediatricians will recommend allowing a fever to persist (within reason) as this is part of the body's natural immune response. Again, there is really no evidence to suggest that use of antipyretics prophylactically will decrease the threshold for febrile seizure in patients with an inherent predisposition.

, the cause is fairly cut and dry. I mean to me, a febrile seizure caused by a fever is fairly avoidable

I don't agree with this statement. I think the patients with a predisposition towards febrile seizures will have the seizures in most cases, and care is generally focused on supportive measures until they "grow out of it." Use of antipyretics is pretty much the same in these patients as it is in patients who show no predisposition, and rarely, these patients will be prescribed some sort of benzo if they happen to be in the small subset that have seizures lasting longer than 10-15 minutes.

, and it's just not a huge deal..

Maybe it's because I have a sister with epilepsy and it's just not a big deal anymore. "Oh look, sister is in her auric phase, let's get her glasses off and move her off the couch in case she pees her pants."

I don't disagree completely with most of what you are saying, I would just be cautious about the tone. Febrile seizure warrants serious consideration by any provider, whether serious intervention is necessary or not.

The best advice in my mind is place the child in a single layer of clothing (onesie, not full bootie pajamas) let them sit in comfortable temperature room air, allow them to control their own thermal regulation (no cool baths, or bundles of septic blankets) and use antipyretics appropriately, making sure to avoid dramatic swings in temperature, and allowing reasonable (sub 102) fever to persist when you can.