In this Clinical Grind episode, Drew, John, and Andy are joined by Pediatric EM physician, Barrie Bostick, to work through a case about pediatric seizures.
Clinical Scenario: You’re working in the community when EMS brings you a 4-year-old child with a known history of seizures who was at the mall with his family when he started seizing. On medic arrival, the child was still seizing and was given intranasal midazolam. Medics said they think the seizures stopped after that.
Are they still seizing?
While assessing ABCs and looking for easily reversible causes by checking a POC glucose, we have to do a focused neurologic exam to determine if the patient might still be seizing. Seizures can have a wide range of presentations, especially in kids, so what do we look for?
- Tonic-clonic movements
- Often the most obvious.
- Even if the tonic-clonic movements stop the child may still be having a seizure.
- Some of the more subtle signs can be harder to differentiate from a post-ictal state.
- Lip-smacking
- Have they started verbalizing again?
- Eye deviation
- Are they making eye contact?
- Quivering of the extremities
How long do you wait before redosing if you think the patient is still seizing?
Generally waiting 2-5 minutes after a dose of benzodiazepines is appropriate before giving another medication, however, you always want to be thinking ahead to your next step. The general algorithm for most patients includes:
- Two to three doses of benzodiazepines including any pre-hospital dosing
- Then move to the second line agent:
- Levetiracetam (Keppra):
- Very commonly used as a go-to second-line agent
- Fewer side effects
- Can be given if the patient is already on it at home
- Often easy to access and used in adults, so staff is more familiar with it.
- Phenytoin and fosphenytoin:
- Greater risk of side effects
- Dosing can be tricky if they are on phenytoin at home
- Phenobarbitol:
- Preferred second-line agent in neonates
- Versed drip
- Levetiracetam (Keppra):
- Be sure to order your second-line medication as you are giving your second round of benzodiazepines because it may take some time to get the medication to the bedside.
- Reach out to your referral hospital or in-house neurologist as soon as possible as they may have more information on what medications have worked in the past along with other key pieces of history that can guide your care.
- Once you’re moving to a second-line agent, begin prepping for intubation.
- The third line is to Intubate and start the patient on propofol.
- When you are at the point of giving a second line agent the patient has likely not been protecting their airway for a decent amount of time and now they are at risk of being hypercarbic with an inability to breathe off the excess carbon dioxide.
Note: Even if the child stops briefly and starts seizing again, you move on to the next agent, you don’t go back to the beginning of the algorithm.
What else should we be ordering?
In most cases, especially new-onset seizures, you want a broad workup.
- Blood work – CBC, CMP, Tox Panel, VBG
- If IV access is an issue, reach for the IO sooner rather than later.
- EKG
- Head CT
- Yes in a patient who has never had a seizure.
- No in a patient who has a known history of seizures.
- Avoid letting the head CT delay transport.
Take-Home Points:
- Examine the patient very closely even when tonic-clonic movements have stopped, looking for subtle signs of seizure.
- Always be thinking one or two steps ahead.
- Don’t wait more than 5 minutes to commit to the next step – time is brain!
- Be sure to consider a broad work-up and wide differential.
- When IV access is challenging, drill the IO!
Post by Patricia Capone, DO PGY-3
About Our Guest:
Barrie Bostick, MD
Pediatric Emergency Medicine Physician, AdventHealth, Orlando, FL
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