Pediatric emergency medicine trisk 2614 2614
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airway, consideration should be given to airway adjuncts and airway positioning.
Noninvasive end-tidal CO2 monitoring can provide valuable assessment but
providers must know how to recognize ineffective ventilation wave forms rather
than simply relying on ETCO2 number. Intravenous (IV) access should be
established promptly; however, because of the potential for increased ICP, fluid
therapy should be used judiciously until a more thorough evaluation is performed.
The child with active convulsions should be protected from trauma.
It is unusual for the child with a brief seizure to arrive in the ED actively
convulsing because, by definition, such seizures last for less than 5 minutes.
Therefore, the actively convulsing child is usually already in a prolonged or serial
seizure state, and pharmacologic intervention to terminate the seizure is required.
Establish IV access, and draw blood for diagnostic studies. If hypoglycemia is
documented by rapid glucose assay or if rapid determination is unavailable, give
IV glucose in a dose of 2 mL/kg of 25% dextrose in water, or 5 mL/kg of 10%
dextrose (use only the latter in infants). If hyponatremia is suspected based on a
history of frequent vomiting or diarrhea or dilution of infant formula, emergent
point-of-care testing for sodium should be performed. Seizures caused by
hypoglycemia or hyponatremia are unlikely to be treated successfully with
anticonvulsant medications without addressing the underlying cause. In neonates
or in children with suspected isoniazid toxicity, IV pyridoxine 100 mg may be
administered.
In most situations, benzodiazepines are the first drug of choice for acute
seizures because of their effectiveness and rapidity of action. Overall
effectiveness is approximately 70% in children, and approximately 15% of
children will require assisted ventilation after receiving benzodiazepines for SE.
While lorazepam (Ativan) is the historically preferred agent by neurologists
because of its long duration of action, recent evidence has not demonstrated
superiority over midazolam (Versed) or diazepam (Valium), and lorazepam causes
prolonged sedation. The ED provider may prefer to use midazolam because it has
the advantage of more rapid return to baseline mental status. Midazolam is also
reliably absorbed when administered intramuscular (IM) or intranasal (IN)
because of its unique ring structure. IM midazolam (10 mg for >40 kg, 5 mg for
13 to 40 kg) or IN midazolam (Versed) of 0.2 mg/kg (maximum 10 mg/dose) has
been shown to be effective. A second dose should be administered if the seizures
do not stop within 5 minutes. Lorazepam is given in a dose of 0.1 mg/kg IV
(usual maximum 4 mg/dose); it has an onset of action of 2 to 5 minutes, and the
duration of anticonvulsant effect is 12 to 24 hours. Lorazepam causes sedation for
several hours in children, which may make it difficult to assess the patient’s
