Pediatric Seizures

BY KAREN OWENS

Scenario: “Medic 1 for the seizure call.” After marking en route, you wait for the additional, “Medic 1, you are en route to 2420 John Drew Parkway for the seizure. Caller states that her daughter had a seizure and is currently unresponsive.” You ask the dispatcher for the patient’s age and history and find out that your patient is an eight-month-old with no history of seizures. As you continue your response, you begin running potential causes through your mind to help prepare your treatment plan.

The pediatric patient can cause anxiety in even the most experienced providers. The potential for so much to change in such a short time is high, and the causes of injury and illness are potentially unknown. Besides, with a child as young as your primary patient, you are no doubt faced with the need to care for the child and the child’s caregiver. Preparing yourself for all possibilities when it relates to pediatric patients is key in good patient care and management.

Within a given year, between 25,000 and 40,000 pediatrics will experience their first seizure.¹ In fact, between 4 percent and 10 percent of children will suffer a seizure before they turn 16.2 Although most of these patients will not ever experience additional seizures, the potential that the seizure is the symptom of a larger issue still exists and should not be discounted.

On scene: On arrival, you find a frantic mother holding a nonresponsive infant in her arms. You notice that the baby has equal rise and fall of the chest and good coloring but does not respond to you or her mother’s attempts to rouse her. You notice she is slightly flushed and appears to be slightly sweaty.

PATIENT ASSESSMENT

With so little known about the patient, it is important to get a good patient and event history from the primary caregiver. You need not only knowledge of the overall medical history but also background on the event itself to determine if this is a provoked or unprovoked seizure. This information will not only help you determine a course of treatment, but it may also help you more specifically determine the cause of the seizure. Along with the standard questions to obtain a history of the event, also ask more specific questions related to the seizure itself. Table 1 provides a sample list of additional questions that you should ask the primary caretaker.

Follow the Pediatric Assessment Triangle (PAT) in your initial assessment of the pediatric seizure patient. It is designed to rapidly create a general impression and gather patient information before touching the patient. This is beneficial with the pediatric patient because it allows the patient and the caregiver time to become comfortable and familiar with you without your having to delay your assessment. In basic emergency management technician (EMT) training, students learn that the PAT relies on three components: appearance, work of breathing, and circulation to the skin.3

Appearance refers to the assessment of overall patient look, interactivity, and responsiveness. (3) Remember that response should be judged based on appropriateness of the patient’s age.

Signs and symptoms of increased work of breathing may include, but are not limited to, noisy breathing, retractions of the intercostal muscles, and supportive positioning. (3)

The third portion of the PAT is circulation to the skin. This may be a bit harder to assess during winter months when kids are bundled up. Look at the extremities, mucous membranes, and central trunk. If the extremities are beginning to show signs of cyanosis and pallor, then it is imperative that you examine the trunk. If the trunk still has good coloring, then the body is still responding to the patient’s decreased cardiac output. (3)

Include a full and detailed set of vitals, including temperature and blood glucose level to determine if the seizure is related to a high fever or low blood sugar. Obtain the patient’s SpO₂ (pulse oximetry) measurement, and assess the patient for any physical injuries that may have resulted from the seizure. These injuries may include contusions, lacerations, or even broken bones. If the seizure caused a fall, the provider may need to consider assessing for spinal injury.

Based on an assessment using the PAT, the pediatric patient described in the scenario is a high-priority transport because of poor appearance.

While gathering additional information on the situation, you find that your patient has been cranky and congested for a few days. When the parents went to get her from her nap, they noticed she was showing seizure-like activity and was hot to the touch. The activity lasted no more than 30 seconds, and she has no history of previous seizures.

CAUSES OF SEIZURES

Febrile seizures are the most common type of seizures in the pediatric patient; the peak age for occurrence is between 18 and 24 months. (2) However, they can occur in any child between the ages of six months and six years. A febrile seizure is the result of a suddenly spiking temperature, normally higher than 101.3oF (38.5oC). Because the seizure occurs before their arrival, first responders will often find that the patient is warmer than normal but no longer has a significantly high temperature. A febrile seizure is normally characterized by the generalized tonic-clonic seizure activity that lasts no more than 15 minutes. (3) Because of the short duration, the patient may not exhibit signs and symptoms when EMS arrives.

Additional causes of seizures in pediatric patients can include the following:

• Brain malformations that occur during development and may lead to pediatric epilepsy.
• Brain tumors, such as gliomas, can develop in children, causing pediatric seizures.
• Infections such as meningitis and encephalitis can lead to inflammation around the brain, causing seizures. Although these additional causes are not common, a strong patient caregiver interview is important in ruling out all potential causes and determining an appropriate course of treatment.

Assessment findings: Based on the information gathered from the mother, your thought is that this appears to be a febrile seizure, but you continue your assessment to rule out additional issues. As you begin a more in-depth assessment, you realize that the patient has begun to react to her environment and is now making eye contact. Her breathing is still adequate with equal rise and fall of the chest, and her skin is normal, warm, and moist. After assessing her vitals, you find that they are within normal limits.

TREATMENT

The assessment findings of the patient provide information to assist you in determining the cause and developing a treatment plan. Treatment is determined not only by the assessment findings and patient history but also by the patient’s current condition. Treatment for the patient who is actively seizing is different from treatment of a patient who is in a post-seizure state.

A patient who is no longer actively seizing may present as awake and oriented, although slightly tired. The patient may also present with an altered mental status. These patients are in a postictal state. (3) This state can last anywhere from five to 30 minutes. Regardless of whether the patient is awake and oriented or altered, the primary concern is to ensure that the patient has a patent and adequate airway. The provider should be prepared to suction and provide supplemental oxygen (if oxygen saturation is low). If the patient is altered and needs assistance in maintaining a patent airway, consider using a nasopharyngeal airway instead of an oral. This is beneficial if the patient begins to have additional seizures during transport. During transport, monitor vitals, ensure adequate airway and breathing, continue to provide supplemental oxygen as necessary, and ensure a safe environment if the patient begins to seize again. Also, if during assessment the patient is found to have low blood sugar, administer glucose to assist in increasing blood sugar levels.

A patient who is actively seizing when EMS arrives on scene presents additional challenges. During an active seizure, your most important job is to protect the patient from further injury during the seizure. When the seizure has stopped, your first action should be to provide supplemental oxygen. If additional seizures occur, then advanced life support (ALS) intervention may be required. An ALS provider may consider obtaining IV access and administering a short-acting benzodiazepine (such as midazolam) to terminate the seizure activity, especially in cases where the duration of the seizure is greater than five minutes. This medication may increase the need to provide supportive airway interventions. As always, the ALS provider should follow local protocols or contact medical control when determining appropriate treatment.

Additional considerations

If the seizures are febrile in nature, consider the use of cold packs to lower the patient’s temperature. Wrap the cold packs in towels before placing them on the patient. The best areas for placement include armpits and neck. Remember not to lower the temperature too quickly, as it could cause the patient to become hypothermic and/or cause heart dysrhythmias.

If additional seizures do occur en route, note the signs, symptoms, and duration of each seizure as well as the consciousness level of the patient in between each event. This additional information will help the hospital staff in treating the patient.

Along with treatment of the seizure, treat any injuries that may have been caused by the seizure. The patient may have soft tissue injuries or additional injuries as a result of the seizure, especially if the seizure caused a fall. Also consider the need for c-spine immobilization if there is concern for spinal compromise.

Although you feel as though this seizure may have been febrile in nature, you believe the mother may feel more comfortable having the child transported to ensure that there is no other cause. Once the patient and her mother are appropriately secured in the ambulance, you begin your transport. During the transport, the patient stays awake and appropriately oriented and maintains a patent and adequate airway with supportive breathing. She does not experience any additional seizures prior to arrival at the ER, and care is transferred without incident.

Although most pediatric seizures are febrile in nature, it is important to consider transport to the most appropriate facility; a pediatric center is preferable. During transport, continued airway support and advanced treatment may be necessary. Regardless of the cause of the seizure, ensuring that the patient’s ABCs are maintained is important to good patient management!

References

1. Chu-Shore, Catherine J. (2013, Mar 27). Pediatric First Seizure. Medscape. Accessed November 15, 2013 from http://emedicine.medscape.com/article/1179097-overview#showall.

2. Friedman, MA & Sharieff, GQ. (2006). Seizures in children. Pediatric Clinics of North America, Elseveir.

3. Pollak, AN. (2011). Emergency Care and Transportation of the Sick and Injured, 10th ed. Jones and Bartlett: Burlington, Mass.

1. What was the patient doing before the seizure began?

2. What did the patient do during the seizure-i.e., did the whole body or just one part of the body shake? Did the patient stare into space?

3. How long did the seizure last?

4. What did the person do after the seizure?

KAREN OWENS is the emergency operations manager for the Virginia Office of EMS, where she has been employed since 2001. Her duties include oversight of emergency operations training, provider health and safety, emergency communications, emergency response, and emergency planning. She has a BA degree in psychology and an MA degree in public safety leadership. She is a Virginia-certified firefighter and has been a Virginia EMT-B instructor since 2002. She is the author of Incident Command for EMS (Fire Engineering).