Pediatric Seizure and Status Epilepticus in the ED

Speaker Introduction

• Speaker: Dr. Maya Holste
• Credentials:
  • MD and Master’s in Public Health from the University of North Carolina Chapel Hill (1999)
  • Pediatric residency at the University of North Carolina
  • Fellowship at the University of Utah (2005)
  • Professor in the Division of Pediatric Emergency Medicine, Primary Children's
• Research Interests:
  • Identification and treatment of status epilepticus in pre-hospital and emergency department settings
  • Published studies and site principal investigator via PECarn Network

Lecture Objectives

• Recognize different types of pediatric seizures
• Identify conditions that mimic seizures
• Define status epilepticus
• Approach to initial support, treatment, and evaluation
• Discuss unnecessary evaluations in new-onset febrile and afebrile seizures

Key Points

Epidemiology

• Seizures affect ~1% of children under 15
• Most common in very young and elderly
• Mortality increases with age

Types of Seizures

• Febrile Seizures:

  • Common, occur with fever
  • Not necessarily indicative of epilepsy
  • Affect 3-4% of children

• Definitions:

  • Seizures: Involuntary motor activity due to hypersynchronous neuronal firing
  • Epilepsy: Two or more unprovoked seizures at least 24 hours apart

Seizure Pathophysiology

• Imbalance of excitatory/inhibitory neuronal currents
• Treatment drugs target cellular ion channels and pathways

Clinical Signs

• Tonic-clonic activity, myoclonic jerks, atonic seizures
• Postictal state: Altered mental status recovery phase
• Indicators: Incontinence, lateral tongue biting, lip smacking

Vital Signs During Seizure

• Hypoxia (bluish lips)
• Blood pressure fluctuations
• Elevated heart rate and temperature
• Possible metabolic changes (acidosis, potassium, glucose levels)

Seizure Classification

• Provoked: Due to external factors (e.g., medication non-compliance, trauma, toxins)
• Unprovoked:
  • No immediate trigger
  • Often linked to genetic or developmental issues

Seizure Activity Misdiagnosis

• Syncope, breath-holding spells, dystonic reactions, and movement disorders can mimic seizures

Status Epilepticus

• Definitions:
  • Seizure >5 minutes
  • Two seizures without recovery
  • Repeated seizures within an hour
• Treatment Goals:
  • Prevent prolonged seizures to avoid neuronal injury
  • Administer benzodiazepines early

Management and Treatment

• Initial Support:
  • Maintain airway, position patient safely to avoid aspiration
  • Oxygen supplementation
  • Monitor blood glucose levels
• Medication Administration:
  • Benzodiazepines (e.g., Midazolam) via IM, intranasal, or rectal routes
  • Subsequent treatments if required include antiepileptic drugs like Keppra

Special Considerations

• Neonates:

  • Higher excitable brain with subtle seizure signs
  • Require more extensive workup for underlying causes

• Non-Convulsive Status Epilepticus:

  • Altered mental status without visible seizure activity
  • Diagnosed with EEG

Febrile Seizures

• Occur in children 6 months to 5 years
• Seizures associated with fever, often self-limiting
• No long-term treatment usually required

Recommendations for EMS

• Early intervention with benzodiazepines
• Support airway without immediate intubation unless necessary
• Provide parental/caregiver education on seizure management and prevention

Closing Remarks

• Importance of EMS in managing pediatric seizures
• Encourage questions and education to improve outcomes

These notes provide a comprehensive overview of Dr. Maya Holste's presentation on pediatric seizures and status epilepticus, capturing the essential details for understanding and managing these conditions effectively.