4.1 Pediatric Seizures, Status Epilepticus & Febrile Seizures

4.1 Pediatric Seizures, Status Epilepticus & Febrile Seizures

Pediatric seizures represent one of the most frequent neurological emergencies encountered in the pediatric emergency department (ED). Seizures result from excessive, hypersynchronous electrical discharges of neurons within the cerebral cortex. In pediatric patients, immature cerebral development, incomplete myelination, and altered GABAergic/glutamatergic receptor balances lower the seizure threshold, making infants and young children particularly susceptible to seizure activity triggered by fever, metabolic disturbances, structural lesions, or systemic infections.

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Etiology and Pathophysiology

Pediatric seizures are classified based on clinical semiology, electroencephalographic (EEG) findings, and underlying etiology:

• Provoked Seizures: Triggered by an acute systemic or CNS insult, including high fever (febrile seizures), hypoglycemia, hyponatremia/hypernatremia, hypocalcemia, hypoxia, acute traumatic brain injury (TBI), toxic ingestion (e.g., organophosphates, tricyclic antidepressants, isoniazid), or central nervous system infections (meningitis, encephalitis).
• Unprovoked Seizures: Occur in the absence of an acute precipitating factor, often reflecting underlying epilepsy syndromes, structural cerebral malformations, or neurocutaneous disorders (e.g., tuberous sclerosis, Sturge-Weber syndrome).

Immediate emergency nursing care prioritizes stabilizing the Pediatric Assessment Triangle (PAT)—assessing appearance (tone, interactiveness, consolability, look/gaze, speech/cry), work of breathing, and cutaneous circulation—to rapidly differentiate transient post-ictal states from ongoing subtle seizure activity or hypoxemia.

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Febrile Seizures: Simple vs. Complex

Febrile seizures are the most common seizure entity in infants and young children, affecting 2% to 5% of children between 6 months and 5 years of age (peak incidence at 12 to 18 months). They occur in the setting of a fever (typically ≥ 38.0°C or 100.4°F) without evidence of intracranial infection, metabolic imbalance, or a history of afebrile seizures. The rapid rate of rise in temperature is often a key triggering mechanism.

Differentiating Simple and Complex Febrile Seizures

Diagnostic Workup & LP Indications

• Simple Febrile Seizure Workup: Routine laboratory testing, neuroimaging (CT/MRI), and EEG are not indicated for a child presenting with a simple febrile seizure who has returned to a normal neurological baseline. The clinical evaluation focuses on identifying the underlying infectious source (e.g., acute otitis media, roseola infantum, viral upper respiratory infection, urinary tract infection).
• Lumbar Puncture (LP) Guidelines: LP must be performed if the child exhibits signs or symptoms of meningitis (nuchal rigidity, Kernig's or Brudzinski's signs, bulging fontanelle, persistent altered mental status). LP is strongly considered in infants aged 6 to 12 months with incomplete or unknown Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunization status, or in children who received prior antibiotic therapy that may mask meningeal signs.
• Antipyretic Counseling: Educate parents that antipyretics (acetaminophen 15 mg/kg, ibuprofen 10 mg/kg for children > 6 months) improve child comfort but do not prevent febrile seizure recurrence.

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Status Epilepticus Protocol

Status Epilepticus (SE) is defined clinically as continuous, unremitting seizure activity lasting ≥ 5 minutes, or two or more discrete seizure episodes without full recovery of consciousness between events. Prolonged seizure activity leads to progressive neuronal injury, metabolic acidosis, hyperthermia, and systemic complications due to excitotoxicity and depletion of cellular energy reserves.

[0 - 5 Minutes: Initial Assessment & Airway]
├── Assess ABCs & PAT (Appearance, Breathing, Circulation)
├── Administer 100% High-Flow O2 via Non-Rebreather; Position Side-Lying
├── Obtain Rapid Point-of-Care Blood Glucose (Rule out Hypoglycemia)
└── Establish Vascular Access (IV/IO) or Prepare Intranasal Route

[5 - 10 Minutes: First-Line Benzodiazepine Administration]
├── Administer First-Line Benzodiazepine (IV/IO Lorazepam, IV/IO Midazolam, or IN Midazolam)
└── If Seizure Persists at 10 Minutes → Repeat First-Line Benzodiazepine Dose ONCE

[10 - 20 Minutes: Second-Line Antiepileptic Infusion]
├── Initiate Second-Line AED Infusion (Levetiracetam, Fosphenytoin, or Valproate)
└── Prepare Continuous Monitoring (ECG, SpO2, ETCO2, Continuous BP)

[> 20 - 30 Minutes: Refractory Status Epilepticus]
├── Prepare for Rapid Sequence Intubation (RSI) & Advanced Airway
└── Initiate Continuous Sedative Infusion (Midazolam, Propofol, or Pentobarbital) + cEEG

Emergency Resuscitation Steps (Time-Critical Pipeline)

1. Minutes 0 to 5 (Stabilization Phase):

   • Maintain airway patency; apply high-flow 100% oxygen via non-rebreather mask or bag-valve-mask (BVM) ventilation if hypoventilating.
   • Position patient in a lateral decubitus (side-lying) position to prevent aspiration of secretions or emesis. Suction oral secretions as needed.
   • Check point-of-care blood glucose immediately. If hypoglycemia is present (< 45 mg/dL in neonates, < 60 mg/dL in infants/children), administer Dextrose 10% (D10W) 2 to 4 mL/kg IV/IO (or D25W 2 mL/kg IV/IO in older children).
   • Apply continuous pulse oximetry, cardiac monitoring, and end-tidal CO2 (ETCO2) capnography.

2. Minutes 5 to 10 (First-Line Benzodiazepines):

   • IV/IO Access Available:
     • Lorazepam (Ativan): 0.1 mg/kg IV/IO (maximum single dose 4 mg) infused slow IV push over 2 minutes. Preferred for its longer duration of action (4-8 hours).
     • Midazolam (Versed): 0.1 mg/kg IV/IO (maximum single dose 5 mg).
   • No IV/IO Access Established:
     • Intranasal (IN) Midazolam: 0.2 mg/kg IN (maximum 10 mg; divided equally between nostrils using a mucosal atomization device [MAD]). Rapidly absorbed across the nasal mucosa directly into the systemic circulation, providing onset comparable to IV administration.
     • Rectal Diazepam (Diastat): 0.2 to 0.5 mg/kg rectally (maximum 20 mg).
   • Repeat Dose: If seizure activity continues 5 minutes after the first dose, repeat the benzodiazepine dose once.

3. Minutes 10 to 20 (Second-Line Antiepileptics):

   • If seizure activity persists beyond 10-15 minutes despite adequate benzodiazepine dosing, immediately initiate a second-line IV/IO antiepileptic drug:
     • Levetiracetam (Keppra): 60 mg/kg IV/IO (maximum dose 4,500 mg) infused over 10 to 15 minutes. Preferred in many centers due to minimal hemodynamically adverse effects and lack of cardiac dysrhythmia risk.
     • Fosphenytoin (Cerebyx): 20 mg Phenytoin Equivalents (PE)/kg IV/IO (maximum dose 1,500 mg PE) infused at a rate up to 150 mg PE/min. Fosphenytoin is a water-soluble prodrug of phenytoin with lower risk of local tissue necrosis (purple glove syndrome) and phlebitis. Requires continuous ECG and blood pressure monitoring due to risks of hypotension and cardiac arrhythmias.
     • Valproate Sodium (Depacon): 40 mg/kg IV/IO (maximum dose 3,000 mg) over 5 to 10 minutes. Avoid in children < 2 years with suspected metabolic or mitochondrial disorders due to severe hepatotoxicity risk.

4. Minutes > 20 to 30 (Refractory Status Epilepticus):

   • Seizures persisting despite second-line therapy constitute Refractory Status Epilepticus (RSE).
   • Require endotracheal intubation, continuous invasive arterial pressure monitoring, continuous electroencephalography (cEEG), and continuous IV sedative infusions (e.g., Midazolam drip 0.05-2 mg/kg/hr, Propofol [caution for Propofol Infusion Syndrome in children], or Pentobarbital/Thiopental coma).

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Nursing Interventions & Clinical Scenarios

Emergency Nursing Care & Safety Checklist

• Airway Protection: Maintain suction equipment at bedside; never force oral airways or tongue blades into a clenched jaw during active seizure activity.
• Environmental Safety: Pad bed rails, remove hard or sharp surrounding objects, and lower bed position to prevent secondary traumatic injury.
• Detailed Documentation: Precisely record seizure onset, total duration, physical motor manifestations (tonic, clonic, focal motor involvement, eye deviation, asymmetry), post-ictal responsiveness, and timing of medication administration relative to seizure cessation.
• Post-Ictal Monitoring: Monitor for respiratory depression, hypoventilation, and airway obstruction secondary to benzodiazepine administration. Ensure BVM and suction are functional.

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Clinical Scenario

An 18-month-old male is brought to the ED by paramedics via ambulance with active generalized tonic-clonic seizure activity lasting 12 minutes. The child has a temperature of 39.4°C (102.9°F). Peripheral IV access could not be established en route. The nurse immediately prepares intranasal midazolam at 0.2 mg/kg using a mucosal atomizer device while placing the child on 100% oxygen via non-rebreather and obtaining a point-of-care blood glucose level (which reads 88 mg/dL). After midazolam administration, seizure activity ceases within 3 minutes. The nurse maintains a side-lying recovery position, monitors SpO2 and ETCO2, and conducts a thorough physical assessment, identifying acute otitis media as the primary fever source.