Exclusives, Patient Care

Pediatric Seizures: Subtle and Often Difficult to Diagnose

Status epilepticus is the most common neurologic emergency in pediatricswith a rate of 18/100,000 cases per year and a mortality of 0–3%.1,2 In a multistate analysis of pediatric EMS transports, seizures were among the 3 most common medical complaints identified.3

Identifying status epilepticus early in the clinical course is important. The longer the seizure persists, the more refractory the seizure becomes which leads to increased morbidity and mortality.4 Given the risk associated with delayed treatment, early identification and treatment is paramount.

Pediatric patients present unique challenges in prehospital seizure management. Ongoing seizure activity in the young child is often overlooked or misinterpreted by EMS providers. This can delay treatment for seizure termination. The frequency of pediatric seizure complaints in the prehospital setting exemplifies the need for EMS providers to be keenly aware of the subtle characteristics of pediatric seizures.

Clinical Presentation & Assessment

Seizures either present in a convulsive or non-convulsive manner.

Convulsive seizures commonly present in a generalized tonic-clonic way that’s typically recognized and treated quickly by EMS personnel. Convulsive seizures may also present with unilateral stiffness or shaking.

In contrast, non-convulsive seizures may be tricky to identify, especially in the pediatric population. Subtle, non-convulsive seizures may be present more commonly in children. Moreover, the younger the pediatric patient, the more subtle the presentation of the seizure.

Clinical features of young children during a seizure may include, but aren’t limited to one of the following:

  • Lip smacking;
  • Facial or extremity twitching;
  • Eye deviation;
  • Jaw clenching; and
  • Cyanosis.

EMS should determine if the child has a history of seizures, and if the patient is taking any antiepileptic medications. In addition, it’s important to know if the child is compliant with the medication. Antiepileptic medication levels are often low due to child growth and inadequate weight-based medication adjustments.

The clinical characteristics of seizures often present alone, with no other symptoms or history. The child who presents with a first-time seizure may lead to a more challenging diagnosis for the EMS provider.3 A thorough history from caretakers should include prior medical conditions, trauma or possible overdose from medications or chemicals.

The EMS provider should have a high index of suspicion for child abuse in any new onset seizure. EMS personnel should perform a careful physical examination on all pediatric seizure complaints. Skin should be exposed and any marks on the child should be reported.

It’s important to pay close attention to vital signs, which may occur as the only hard evidence of an active seizure on an altered child who is having a non-convulsive seizure. The altered child may be post-ictal or actively seizing, albeit presenting in a non-convulsive state.

Vital sign abnormalities in an active pediatric seizure may include marked tachycardia (i.e., around 200 beats per minute), hypoxia and/or tachypnea. In conjunction with abnormal vital signs, the patient should be evaluated for the aforementioned subtle characteristics (i.e., lateral eye deviation, jaw clenching, twitching or rigidity).

In general, seizures customarily stop prior to EMS arrival. However, if the child is still seizing on EMS arrival, then prolonged seizure activity (i.e., status epilepticus) should be assumed.3 Status epilepticus is defined as any seizure lasting greater than five minutes, or when multiple seizures occur without gaining a normal level of consciousness in between seizures.Over the last two decades, the definition of status epilepticus has shortened from greater than 20 minutes to greater than five minutes in duration due to the increased morbidity and mortality associated with prolonged seizures.5

Treatment

The prehospital management of pediatric seizure focuses first on airway, breathing and circulation, followed by terminating the seizures with a benzodiazepine and preventing the recurrence of the seizure. It’s then important to identify treatable causes, such as hypoglycemia, hypoxia, toxic ingestion or trauma, and to prevent the child from further injury.3

The standard treatment for pediatric seizures in the prehospital field is benzodiazepine administration and checking blood glucose.

Midazolam is the benzodiazepine used most frequently in EMS agencies due to its ease of use and multiple quick routes of administration. Midazolam may be administered via intranasal (IN), intramuscular (IM),  intravenous(IV) or intraosseous(IO) routes. Multiple studies have looked at diazepam and midazolam for cessation of pediatric seizure activity and have determined that both medications are efficacious and safe when used in the prehospital setting. Dosing for midazolam is 0.1–0.2 mg/kg via IN/IM and 0.05–0.1 mg/kg via IV/IO.

Most EMS protocols recommend checking blood glucose after benzodiazepine administration for active seizures. If blood glucose is less than 60mg/dL, then dextrose must be administered IV/IO per the recommended length-based measurement dose used by the provider’s agency.

Education & Innovation

Pediatric seizures in the prehospital field are difficult to identify and often go unrecognized by EMS personnel. Research studies have looked at paramedic identification of pediatric status epilepticus in the prehospital field and, unfortunately, the evidence points to delayed treatment. Only 44–65% of pediatric patients in prehospital status epilepticus receive benzodiazepine drugs.1,2

To make pediatric seizures more complex, protocols are oftentimes inconsistent among EMS agencies. A recent study of county EMS agencies in California displayed a wide variety of pediatric seizure protocols. Protocols ranged in drug dosages, along with redosing requirements, routes of administration and time sequence for checking blood glucose prior to medication administration.6

Preliminary studies in the Los Angeles County and the University of Southern California (LAC+USC) ED show that paramedics miss approximately 50% of active seizures. The most common missed features for subtle or non-convulsive seizure presentation is abnormal vital signs, gaze deviation and jaw clenching.7

LAC+USC has therefore implemented a change to the online medical direction protocol for pediatric seizure calls. For pediatric seizures in patients who are reportedly post-ictal or have altered mentation in the field, EMS providers are asked to further assess the child and look for any signs of the following: 1) jaw clenching; 2) gaze deviation; or 3) stiff arms or legs? If any one of these three things are present, then the child is assumed to be actively seizing and orders for benzodiazepine administration are given.8

This has anecdotally proven to reassure the online medical direction administrator, along with the paramedic in the field, to assuredly treat the child who may still be actively seizing. The ED staff has also appreciated this extra assessment, which has led to prompt termination of seizures in the field.

Finally, a crucial component in advancing education and patient care is real time feedback in the ED.9 The LAC+USC ED is working diligently on creating a positive learning culture, which affords direct feedback from our physicians and nurses to the EMS crew. This feedback and education has helped EMS providers build confidence and improve patient care on the stressful pediatric seizure call.

References

1. Sánchez Fernández I, Abend NS, Agadi S, et al. Time from convulsive status epilepticus onset to anticonvulsant administration in children. Neurology. 2015;84(23):2304–2311.

2. Shatirishvili T, Kipiani T, Lomidze G, et al. Short-term outcomes and major barriers in the management of convulsive status epilepticus in children: A study in Georgia. Epileptic Disord. 2015;17(3):292–298.

3. Micheal G, O’Connor R. The diagnosis and management of seizures and status epilepticus in the prehospital setting. Emerg Med Clin North Am. 2011;29(1):29–39.

4. McMullan JT; Duvivier EH, Pollack CV (eds.): Seizure disorders. In Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s emergency medicine: Concepts and clinical practice, 8th edition. Mosby: St. Louis, pp. 1375–1385, 2014.

5. Schachter S, Shafer PO. (n.d). Status Epilepticus. Epilepsy Foundation. Retrieved Dec. 18, 2018, from www.epilepsy.com/learn/challenges-epilepsy/seizure-emergencies/status-epilepticus.

6. Silverman EC, Sporer KA, Limieux JM, et al. Prehospital care for the adult and pediatric seizure patient: Current evidence based recommendations. West J Emerg Med. 2017;18(3):419–436.

7. Abramson T, Crow E, Rose E, et al.  Identifying Active Pediatric Seizures: Paramedic Sensitivity and Specificity. [Ongoing study.]

8. Abramson T, Loza-Gomez A, Kearl Y. Base hospital nurse education for pre-hospital identification of pediatric status epilepticus [conference presentation]. National Association of EMS Physicians Annual Conference, 2017.

9. Wacht O, Oz E, Strugo R. (March 1, 2017) Feedback in EMS: Do we really know if our diagnosis is correct? JEMS. Retrieved Jan. 13, 2019, from www.jems.com/articles/2017/03/feedback-in-ems-do-we-really-know-if-our-diagnosis-is-correct.html.