PEDIATRIC SEIZURES

Diagnosis
• True seizure vs pseudoseizure
• Febrile seizure vs non-febrile seizure
• Simple vs complex febrile seizure

Workup
• Lab tests
• Lumbar puncture
• Brain CT scan

Treatment
• Seizure algorithm
• Parents counselling
DIAGNOSIS
 Pediatric seizures
Shiver
No Pseudoseizure/
True seizure? Breath holding spell
seizure mimics Syncope
Yes

No Non-febrile Central causes:

Febrile? Intracranial mass
seizures
Intracranial bleeding
Yes Meningitis

Metabolic causes:
Febrile seizures Hypoglycemia
Hyponatremia

Simple Complex
febrile seizures febrile seizures

Causes:
Viral infections
Bacterial infections: meningitis, otitis media, URTI, LRTI, diarrhea
 Recognizing True Seizure
Not True Seizure
True Seizure
Breath holding spell Pseudoseizure Syncope
• Lateralized • Clear trigger • Adolescent Decreased of
tongue-biting (emotional pretending to consciousness
(high-specificity) distress, crying) have seizure always precedes any
• Flickering eye-lids • No post-ictal • Side-to-side head perceived seizure
• Dilated pupils with phase • Arm or leg activity
blank stare movements with
• Lip smacking eye closed
• Increased HR and • Bicycling
BP movement of legs
• Post-ictal phase
 Simple vs Complex Febrile Seizure
Simple Febrile Seizure Complex Febrile Seizure
Age 6mos to 5yrs Any
Frequency 1x in 24hrs >1x in 24hrs
Nature Generalized Focal/generalized
Duration Lasting <15 min >15 min
Recovery Post-ictal with return to Post-ictal may not fully
baseline and normal return to normal if multiple
neurological exam seizures

Simple febrile seizures tend to occur early in the illness within 24hrs of onset of fever.
If the seizure occurs >24hrs after the onset of fever, the suspicion for a bacterial and/or
pathologic cause should be heightened.
WORKUP
 LAB TESTS
• CBC
• Electrolyte
• Blood glucose
 LUMBAR PUNCTURE
LP should be performed in:

neck stiffness
Febrile seizure  suspected meningitis Kernig sign
Brudzinski sign
or

have not received Hib/pneumococcal vaccinations

Infants 6 - 12mos  febrile seizure 
unknown vaccination status
 BRAIN CT SCAN
Head CT scan is indicated in:
• Focal seizure or persistent seizure activity
• Focal neurological deficit
• VP shunt
• Signs of elevated ICP
• History of trauma
TREATMENT
1. Stabilize patient (ABCD)
2. Time seizure from its onset, monitor vital signs
3. Assess oxygenation, give O2, consider intubation if needed
4. Initiate ECG monitoring
5. Collect finger stick blood glucose
6. Attempt IV access and collect electrolytes, hematology, toxicology
scren

Rectal diazepam
BW <10 kg = 5 mg
BW > 10 kg = 10 mg

Or

Intravenous diazepam
0.3-0.5 mg/kg over 3-5 min (0.5-1 mg/min), max 20mg

Intravenous phenytoin
Loading dose: 15-20 mg/kg (rate 25 mg/min)
Maintenance dose: 5-7 mg/kg/day, BD, 12h after LD

Intravenous phenobarbital
Loading dose: 10-20 mg/kg
Maintenance dose: 3-4 mg/kg/day, 12h after LD
 PARENTS COUNSELLING
• Safety
– Place the child in recovery position and do not place
anything in mouth
• Risk of recurrence
– Age <18 months
– Duration of fever <1 hour before seizure onset
– 1st degree relative with febrile seizure
– Temperature <40oC
(No risk factor = 14%, all risk factors present = 70%)
• Risk of epilepsy
– Approx. 2% after simple febrile seizure
– Approx. 5% after complex febrile seizure
THANK YOU