Pediatric emergency medicine trisk 1433 1433
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The patient’s circulatory status must also be closely monitored. Seizures
generally cause a massive sympathetic discharge that result in hypertension and
tachycardia. Continuous monitoring and intravenous (IV) access should be
obtained. Blood samples, including rapid blood glucose and sodium testing,
should be acquired at this time. Hypoglycemia should be corrected urgently, yet
mild stress hyperglycemia during seizure episode usually does not require
treatment. Peripheral IV access, which is often difficult in the pediatric age group,
may be nearly impossible in the actively seizing patient. Intraosseous and/or
central venous access may be required in the patient with prolonged seizures.
Once the respiratory and circulatory functions have been assessed and
maintained, efforts should be directed at stopping any ongoing seizure activity
and making a diagnosis. As long as adequate ventilation and oxygenation are
maintained, long-term sequelae are unlikely to result from a transient seizure.
Consensus management suggests the initiation of anticonvulsant treatment of
anyone who has been seizing for more than 5 minutes. This likely represents all
patients who are brought to the ED actively seizing.
EVALUATION AND DECISION
History
As a result of the numerous potential causes of seizures, as well as the large
number of events that can be mistaken for a seizure, a focused history is
important. The parent or caregiver needs to carefully describe the episode and the
preceding events. Was there a warning (aura) that the patient was about to have an
event? Was there a loss of consciousness, tongue biting, or incontinence? Did the
event involve the entire body or only a portion? How long did the event last?
How did the patient act after the event was over? The clinician should take into
account that the event characteristics may not be accurately perceived by a
distressed parent. With smartphones and digital media being more common,
parents may present a video clip of the event to the treating clinician, especially
for recurring events.
In addition to the episode itself, the preceding events are also crucial. Was there
a history of trauma, toxin exposure or ingestion, fever, or other systemic signs of
illness (e.g., headache, ataxia, vomiting, diarrhea)? Does the child have an
underlying seizure disorder, history of seizures, or other neurologic problems? Is
the child taking any anticonvulsants? If yes, was there a recent change in dose, or
were any medications started or stopped? Is there a chance that the patient could
have a subtherapeutic level, especially if there were any recently missed doses?
