Seizure Acute Management: Emergency Department v.1.

2
Executive Summary

Explanation of Evidence Ratings

Inclusion Criteria
Patient presenting with
epileptic seizure

Test Your Knowledge

Summary of Version Changes

Exclusion Criteria
Age < 1 month corrected
age
Non-epileptic events
(pseudoseizures)

!
Confirm
medication history.
If seizing upon arrival
skip to appropriate step

!
Known epilepsy:
check outpatient
seizure plan

Definitions
Prolonged Seizure/Status Epilepticus: seizure longer than 5 minutes or
two or more seizures without a return of consciousness between seizures

General Measures

Drug Treatment

Investigations

Position child to avoid injury

Cardiorespiratory support as needed
SaO2; support respiration including
provision of high concentration oxygen
Make NPO/hold feeds while seizing
Document seizure start time (consider
using Code Blue Sheet)
Check Care Plan/Care Coordination for
individualized seizure care plan
Prepare/obtain next medication
Consider IV placement

Minute 0
1st Step

None

Confirm clinically that it is an

epileptic seizure
Assess risk for infection (if fever,
see also Febrile Seizure Pathway)
Investigate prior medications given

Seizure continues

Minute 5
2nd Step

Drugs (1st Line)

General Measures

Investigations

Above plus
Cardiorespiratory monitoring, blood
pressure q 5 minutes
Correct hypoglycemia
Prepare/obtain next medication

IV access
Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access
Midazolam 0.2mg/kg max 10mg/
dose, dose in each nostril

Physical examination and history

If on antiepileptic medication:
consider drug level
Consider laboratory tests based on
individual clinical circumstances

Seizure continues

Minute 15
3rd step

Drugs (1st Line)

Investigations

General Measures

IV access
Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access
Midazolam 0.2mg/kg max 10mg/
dose, dose in each nostril

Re-confirm clinically that it is an

epileptic seizure

Above plus
Capnography
Prepare/obtain next medication

Seizure continues

Minute 25
4th Step

Drugs (2nd Line)

Investigations

General Measures

Order customized treatment plan if

available. If not available, use default
below:

Above plus
Use blood pressure (BP) support if
needed
Identify and treat medical complications
Consider PICU and Neurology consult
*Decrease loading dose if patient already
established on phenobarbital or
fosphenytoin

Age 1-2 months old

Phenobarbital 20mg/kg IV loading
dose*
Age > 2 months old
Fosphenytoin 20mg PE/kg IV*

As above
Consider CT
Consider EEG

!
Watch for
B/P changes
in patients with
cardiac anomalies or
hemodynamic
instability

Seizure continues

Post-Ictal

Minute >40
5th Step

Drugs (2nd Line)

Age 1-2 months old
May give additional phenobarbital
5mg/kg IV doses every 15-30 minutes
until 30mg/kg maximum is met*
Age > 2 months old
Phenobarbital 20mg/kg IV if seizure
continues 15 minutes after
fosphenytoin load*
May give additional phenobarbital
5mg/kg IV doses every 15-20 minutes*

Investigations

General Measures

As above

Above plus
Off pathway, transfer to PICU
In consultation with Neurology, optimize
maintenance antiepileptic drug treatment
*Decrease loading dose if patient
already established on phenobarbital or
fosphenytoin

Treatment and General Measures

Ongoing vital signs q 10 minutes until stable
Ongoing cardiorespiratory and SpO2 monitoring until
return to baseline
Family support
Discuss with primary neurologist

Admit Criteria
Unstable cardiorespiratory or neurologic status (not
returing to baseline, very somnolent)
Underlying infection requiring inpatient stay
Disabling parental anxiety
Lack of safe home or safe transportation to home

For questions concerning this pathway,

contact: [email protected]
2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 6/11/2013

Valid until: 6/19/2015

Seizure
stops

Seizure Acute Management: Inpatient v.1.2

Inclusion Criteria
Patient presenting with seizure
Patient admitted with history of
epileptic seizures and risk of
recurrence

Exclusion Criteria

Age <1 month corrected age

In hospital for Video EEG
Non-epileptic events
(pseudoseizures)
Contraindications to use of pathway
medications
Patient has customized
seizure plan

Confirm
medication history.
Skip to appropriate step

Definitions
Prolonged Seizure/Status
Epilepticus: seizure longer than 5
minutes or two or more seizures
without a return of consciousness
between seizures

On
Admit

Upon Admission
Order benzodiazepine from Seizure Acute Management First-line Orderset
Order either Seizure Acute Management Second-line Orderset OR patients customized second-line meds based on
Neurology recommendations
If patient is in ICU, discuss appropriateness of pathway inclusion with attending
Seizure occurs

General Measures

Drug Treatment

Investigations

Position child to avoid injury

Cardiorespiratory & SaO2 monitoring
Support respiration including provision
of high concentration oxygen
Make NPO/hold feeds while seizing
Document seizure start time
Prepare/obtain first medication
Notify Contact Provider
Consider IV placement

Minute 0
1st Step

None

Assess risk of infection (if fever,

see Febrile Seizure Pathway)
Investigate prior medications given

Seizure continues
st

Minute 5
2nd Step

Drugs (1 Line)

Investigations

General Measures

IV access
Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access
Midazolam 0.2mg/kg max 10mg/
dose, dose in each nostril
Midazolam 0.5mg/kg buccally max
dose 10mg if nares not available

Above plus
Assess vital signs with B/P every 5
minutes
Prepare/obtain next medication
Notify Contact Provider if medication
given. Call MD to bedside

Physical examination and history

If on an antiepileptic medication:
consider drug level
Consider laboratory tests based on
individual clinical circumstances

Seizure continues

Minute 15
3rd Step

Drugs (1st Line)

General Measures
Above plus
Call Vascular Access Team for
STAT IV access
Notify Contact Provider if medication
given. Call MD to bedside.
Prepare/obtain next medication
Call Rapid Response Team and
consult Neurology

IV access
Lorazepam 0.1 mg/kg max 4mg/
dose administered IV 2mg/min
No IV access
Midazolam 0.2mg/kg max 10mg/
dose, dose in each nostril
Midazolam 0.5mg/kg buccally max
dose 10mg if nares not available

Investigations
Re-confirm clinically that it is an
epileptic seizure

Seizure
stops

Seizure continues

General Measures

Minute 25
4th Step

Drugs (2nd Line)

Order customized treatment plan if
available. If not available, use default
below:
Age 1-2 months old
Phenobarbital 20mg/kg IV loading
dose*
Age > 2 months old
Fosphenytoin 20mg PE/kg IV*

Above plus
Blood pressure (BP) support if
needed
Identify and treat medical
complications
*Decrease loading dose if patient
already established on
phenobarbital or fosphenytoin

Investigations
As above
Consider CT
Consider EEG

!
Watch for
B/P changes
in patients with
cardiac anomalies or
hemodynamic
instability

Seizure continues

PostIctal

Minute >40
5th Step

Drugs (2nd Line)

Age 1-2 months old
May give additional phenobarbital
5mg/kg IV doses every 15-30 minutes
until 30mg/kg maximum is met*
Age > 2 months old
Phenobarbital 20mg/kg IV if seizure
continues 15 minutes after
fosphenytoin load*
May give 2 additional phenobarbital
5mg/kg IV doses every 15-20 minutes
(total 30mg/kg maximum)*

General Measures
Above plus
In consultation with Neurology,
optimize maintenance
antiepileptic drug treatment
Off Pathway, transfer to PICU
*Decrease loading dose if
patient already established on
phenobarbital or fosphenytoin

Investigations
As above

Treatment and General Measures

Ongoing vital signs q 10 minutes until stable
Ongoing cardiorespiratory & SaO2 monitoring until at baseline
For questions concerning this pathway,
contact: [email protected]
2012, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Family support
Discuss with primary neurologist
Last Updated: 6/11/2013
Valid until: 6/19/2015

Return to ED Management

Return to Inpatient Management

Definition of Prolonged Seizure

A proposed Classification of Status Epilepticus
according to length of seizure:
5-30 Minutes: (OR 2 or more seizures without returning to baseline):
Prolonged Seizure/Early Status Epilepticus.

30-60 Minutes: Established Status Epilepticus.

Greater than 60 Minutes: Refractory Status Epilepticus.
[Expert Opinion (E)] (Glauser ,2007; Ma, 2010; NICE, 2012)

Definitions
Prolonged Seizure/Status Epilepticus: seizure longer than 5
minute or two or more seizures without a return of
consciousness between seizures.

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Actively Seizing
For the child that is actively
seizing, obtain history of all antiseizure medications given around
this seizure episode to:

Prevent medication overdosing

Prevent medication interactions

Decide where the patient belongs on

the pathway

e.g., the patient that is still seizing at

presentation to the ED after receiving
2 doses of benzodiazepines in the
field, should proceed to second-line
agents after the appropriate time
interval.

Return to ED Management

ED:

Inpatient:

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When should treatment begin?

Give immediate emergency care and treatment to children,

young people and adults who have prolonged (lasting 5 minutes
or more) or repeated (3 or more in an hour) convulsive seizures
in the community.
Serious risk of immediate and long-term morbidity and mortality if convulsive
seizure is not terminated by 30 minutes and therefore treatment is required
urgently. [ Low quality] (NICE, 2012)

Patients arriving at the hospital with a seizure can be considered

as having a prolonged seizure.
A pre-hospital trial showed that time from seizure onset to initiation of treatment
was inversely correlated with the percentage of patients who responded to firstline therapy. Patients receiving first-line therapy within 30 minutes had >80%
response rate compared to 75% within 60 minutes and 63% within 90 minutes.
[ High quality] (Ma, 2010)

Drug therapy for prolonged seizure

Drug therapy for prolonged
seizures consists of :
A first-line agent

PLUS

A second-line agent

To Pg 2

Drug therapy for prolonged seizure 1st line

Benzodiazepines are first-line

agents. First dose should be given
at 5 minutes after start of seizure.
Dose may be repeated after 10
minutes if patient still seizing.

Administer intravenous lorazepam

as first-line treatment in hospital in
children, young people, and adults
with ongoing generalized tonicclonic seizures.

Administer intranasal OR buccal

midazolam if unable to secure
immediate IV access.
[ Low quality] (NICE, 2012)

Drug therapy for prolonged seizure 1st line

Administer a maximum of two

doses of the first-line treatment
(including pre-hospital treatment).
[ Low quality] (NICE, 2012)

The first dose of the patients

second-line treatment should be
requisitioned from the pharmacy
immediately after giving a second
dose of benzodiazepine.
This gives the pharmacy adequate
time to prepare the medication so
that it can be given on-time if the
patient continues to seize.

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Drug therapy for prolonged seizure 2nd line

Second-line therapy after

benzodiazepines is fosphenytoin or
phenobarbital.

Fosphenytoin is preferred for patients

age greater than or equal to 2 months.

Cardiorespiratory and blood pressure

monitoring must accompany the IV
administration of Fosphenytoin.
[ Very low quality] (Ma, 2010)

First dose of these agents should be given

at 10 minutes after the second
benzodiazepine dose. Dose may be
repeated after an additional 15 minutes if
patient still seizing.

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Drug therapy for prolonged seizure 2nd line

Cautions:

Fosphenytoin has direct cardiac

effects which can lead to
arrhythmias.

Hypotension, though rare, does

occur with fosphenytoin.

Phenobarbital can cause

hypotension from its vasodilatatory
and cardiodepressant effects

Phenobarbital can cause profound

respiratory depression.

Return to ED Management

!
Watch for
B/P changes in
patients with
cardiac anomalies

Return to Inpatient Management

Drug therapy for prolonged seizure

At Admission
Order benzodiazepine from Seizure Acute Management Firstline Orderset
Order either Seizure Acute Management Second-line
Orderset OR patients customized second-line meds based on
Neurology recommendations

All inpatients with a significant history of seizures should have as

needed doses of first-line AND second line seizure rescue agents
ordered as part of their admitting orders, so that they are readily
available.

Some patients with a history of frequent, prolonged and /or

intractable seizures may use other agents other than fosphenytoin
or phenobarbital for their second-line treatment. Neurology
should be consulted for these patients.

Return to ED Management

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General measures for acute seizure

Immediately:

Give high-concentration oxygen

Assess cardiac and respiratory function
Check blood glucose levels
Secure IV access in a large vein
Secure airway
[Expert Opinion (E)] (NICE, 2012)
If patient receives a dose of
benzodiazepine, continuously monitor
and manage cardio respiratory function.
[Expert Opinion (E)]
Check blood pressure every 5 minutes
during seizure, then every 10 minutes
during postictal period until stable.
[Expert Opinion (E)]

General Measures

Seizure

Continues

General Measures

Return to ED Management

Position child to avoid injury

Cardiorespiratory support as needed
SpO2; support respiration including
provision of high concentration oxygen
Make NPO/hold feeds while seizing
Document seizure start time (consider
using Code Blue Sheet)
Check Care Plan / Care Coordination
for individualized seizure care plan
Prepare/obtain next medication
Consider IV placement

Above plus
Cardiorespiratory monitoring, blood
pressure q 5 minutes
Correct hypoglycemia
Prepare/obtain next medication

Return to Inpatient Management

Laboratory evaluation for acute seizure

Anti-epileptic drug (AED) levels should be

considered when a child with epilepsy on AED
prophylaxis develops prolonged seizure/SE.

Investigations

Confirm clinically that it is an

epileptic seizure

[ Low quality] (Riviello, 2006)

Assess risk for infection (if fever, see

also Febrile Seizure Pathway)

Laboratory tests (complete blood count (CBC),

serum electrolytes, blood urea nitrogen (BUN),
creatinine, glucose, calcium, magnesium, or
stool studies) should be considered based on
individual clinical circumstances that include
suggestive historic or clinical findings such as
vomiting, diarrhea, dehydration, or failure to
return to baseline alertness.

Investigate prior medications given

[ Very low quality] (Riviello, 2006)

Investigations

Physical examination and history

If on antiepileptic medication:
consider drug level

Consider laboratory tests based on

individual clinical circumstances

Laboratory evaluation for acute seizure

Toxicology testing may be considered in children with prolonged
seizure/SE, when no apparent etiology is immediately identified, as the
frequency of ingestion as a diagnosis was at least 3.6%. To detect a
specific ingestion, suspected because of the clinical history, it should be
noted that a specific serum toxicology level is required, rather than
simply urine toxicology screening.
[ Very low quality] (Riviello, 2006)

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Bacterial cultures for acute seizure

There is insufficient data to support or refute whether blood

cultures should be done on a routine basis in children in whom
there is no clinical suspicion of infection. [ Very low quality]
(Riviello, 2006)

There is insufficient data to support or refute whether lumbar

puncture should be done on a routine basis in children in whom
there is no clinical suspicion of a CNS infection. [ Very low
quality] (Riviello, 2006)

A lumbar puncture should be performed in any child who presents

with a seizure and a fever and has meningeal signs and symptoms
(e.g., neck stiffness, Kernig and/or Brudzinski signs). [
Moderate quality] (AAP, 2011)

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Assess Risk of Meningitis or Intracranial Infection

A lumbar puncture should be performed in any child with seizure and a fever
who is felt to be at SIGNIFICANT RISK for meningitis/intracranial infection.
Specific aspects of the history or exam that might suggest meningitis or
intracranial infection are outlined in the table below:

[ Low quality] (Baumer, 2004; Selz, 2009; Kimia, 2010; Batra, 2011; AAP, 2011; Fetveit, 2008),
[Expert Opinion (E)] (AAP, 2011; BC Guideline, 2011)

More detail on this subject can be found in the Febrile Seizure Learning Module.

Assess Risk of Meningitis or Intracranial Infection

Children with the following HISTORICAL features have an increased risk
of meningitis and lumbar puncture should be CONSIDERED:

A child with at least three days of illness, seen by GP in

previous 24 hours, with drowsiness at home, or
vomiting at home. [ Low quality] (Baumer,
2004)
An infant between 6 and 12 months of age who is
considered deficient in Haemophilus influenzae type b
(Hib) or Streptococcus pneumoniae immunizations (i.e.,
has not received scheduled immunizations as
recommended) or when immunization status cannot be
determined because of an increased risk of bacterial
meningitis. [Expert Opinion (E)] (AAP, 2011)
A child who is pretreated with antibiotics, because
antibiotic treatment can mask the signs and symptoms
of meningitis. [Expert Opinion (E)] (AAP, 2011)

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History
>3 days duration of illness
Seen by primary MD in
previous 24 hours
Drowsiness or vomiting at
home
Infant 6-12 months old
deficient in Hib or
pneumococcal vaccines or
immunization status cannot
be determined
Pretreated with antibiotics

Assess Risk of Meningitis or Intracranial Infection

Children with the following PHYSICAL EXAM features have an
increased risk of meningitis and lumbar puncture should be
CONSIDERED:

Children with petechiae, questionable nuchal rigidity,

drowsiness, convulsing on examination, weakness on
examination, bulging fontanel. [ Low quality] Baumer,
2004)

Some studies have suggested that abnormal neurological or

mental status examinations are most predictive of meningitis/
intracranial infection: patients are described as obtunded,
comatose, unresponsive, lethargic, drowsy, prolonged postictal state, agitated, combative, irritable, cranky, clingy,
moaning, toxic. [ Low quality](Selz, 2009; Kimia,
2010; Batra, 2011; AAP 2011)

Signs of infection of the head or neck with potential for

intracranial extension (such as mastoiditis, sinusitis, etc.)
[Expert Opinion (E)]

Physical Signs
Petechiae
Questionable nuchal rigidity
Drowsiness
Convulsing on examination

Weakness or neurological
deficit on examination
Signs of infection of head or
neck with potential for
intracranial extension (such
as mastoiditis, sinusitis, etc.)
Bulging fontanelle

No evidence was found to support the suggestion that

children below a certain age do not exhibit the signs of
meningitis. (Baumer, 2004)

Assess Risk of Meningitis or Intracranial Infection

Children with COMPLEX FEBRILE SEIZURES may have an increased
risk of meningitis and lumbar puncture should be CONSIDERED
There is some inconsistency in the literature regarding the approach to patients with
complex febrile seizures (CFS).

Two guidelines state that LP should be CONSIDERED in

children with CFS. [ Low quality] (Baumer, 2004;
Fetveit, 2008)

One guideline RECOMMENDS lumbar puncture for all

patients with CFS. [Expert Opinion (E)] (Boyle, 2011)
And one guideline makes no distinction between children
with CFS and children with simple febrile seizures (SFS)
when assessing their risk of meningitis/intracranial infection.
[Expert Opinion (E)] (BC Guideline, 2011)

Complex Features
Focal Seizures
Seizure duration > 15 minutes
Multiple seizures in 24 hours

The PAERG systematic review looked a 4 studies from 1981 -92, and found
that the historic pooled rate for meningitis following febrile seizure was 2.9%
overall, with a rate of 2% in SFS and 9.1% in CFS. [ Low quality]
(PAERG, 2002)

However, recent studies in the age of Hib and Pneumococcal vaccines have
shown the rate of meningitis CFS to be very low at <1%, [ Low
quality] (Selz, 2009; Kimia, 2010) and similar to the rate for SFS. [
Low quality] (Trainor, 2001)

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Assess Risk of Meningitis or Intracranial Infection

Children with a previous history of febrile
seizures or history of pre-existing
neurological abnormality may be less likely
to have meningitis or intracranial infection
associated with subsequent febrile seizures.
[Expert Opinion (E)]

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Meningitis Less Likely

Prior febrile seizure
Pre-existing neurological
findings

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Urgent EEG in evaluation of acute prolonged seizure

Consult neurology to discuss need for emergent EEG.

In adults, nonconvulsive SE (NCSE) is present in

14% of patients in whom convulsive SE is
controlled but in whom consciousness remains
impaired. Although nonconvulsive SE occurs in
children who present with prolonged seizure/SE,
there is insufficient data to support or refute
recommendations regarding whether an EEG
should be obtained to establish this diagnosis.
[ Very low quality] (Riviello, 2006)

Investigations
As above
Consider EEG
Consider CT

An EEG may be considered in a child presenting

with prolonged seizure/SE if the diagnosis of
pseudostatus epilepticus is suspected.
[ Low quality] (Riviello, 2006)

Urgent CT in evaluation of acute prolonged seizure

Emergent neuroimaging (CT) may be considered for the evaluation of

the child with prolonged seizure/SE if any of the following are present:
o Unknown etiology of seizure
o Acute change in neurologic exam from baseline
o Suspicion for non-accidental trauma

o Focal seizure onset

o Pre-disposing history (age <6 months, trauma, CSF shunt,
malignancy, or neurocutaneous disorder).
o First seizure lasting > 30 minutes

If neuroimaging is done, it should only be done after the child is

appropriately stabilized.

There is insufficient evidence to support or refute recommending routine

neuroimaging. [ Low quality] (Riviello, 2006; Harden, 2007)

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Refractory Seizure Patients are Off-Pathway

Patients who continue to seize after Step 5 are

OFF THE PATHWAY

Further evaluation and treatment should be directed by

Neurology and the Intensive Care Unit.

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Criteria for Inpatient Admission

Once seizures have resolved, the patient should continue to be

monitored and observed until patient is returning to baseline.

Addressing parental anxiety and providing parental education are

often the key tasks of the medical team following a seizure.

Criteria for Inpatient Admission

Admit Criteria

ED Patients

Unstable cardiorespiratory or neurologic status (not

returing to baseline, very somnolent)
Underlying infection requiring inpatient stay
Disabling parental anxiety
Lack of safe home or safe transportation to home

Children who are clinically unstable neurologically (e.g., not returning to

baseline, very somnolent following doses of anti-seizure medications) should be
admitted for observation and support. [Expert Opinion (E)] (Fetveit, 2008;
Baumer, 2004)
Children who present with an underlying infection requiring inpatient stay (e.g.,
severe pneumonia, infection requiring intravenous antibiotics) should be
admitted. [Expert Opinion (E)] (BC, 2010)
Children whose parents have "disabling" anxiety following the seizure episode
may require admission for observation and further parental education and
reassurance. [Expert Opinion (E)](BC, 2010; Fetveit, 2008)
Children that lack a safe home or safe transportation home require admission
and may require social work consultation. [Expert Opinion (E)] (Fetveit, 2008)

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Executive Summary

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Executive Summary

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Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
1) Which of the following is FALSE regarding inclusion and exclusion criteria?
a) The Seizure Acute Management pathway should be used for patients with non-epileptic seizures (a.k.a. pseudoseizures
or 'spells')
b) Patients less than 1 month old (44 weeks gestational age) are excluded from the pathway
c) For inpatients, the Seizure Acute Management Pathway should be ordered for all patients presenting with seizure
d) For inpatients, the Seizure Acute Management Pathway should be ordered for all patients with a history of epileptic
seizures and risk of recurrence
2) Which of the following statements about seizures are TRUE?
a) A seizure lasting 5-30 minutes or 2 or more seizures without returning to baseline is classified as: "Prolonged Seizure/
Early Status Epilepticus"
b) A pre-hospital trial showed that time from seizure onset to initiation of treatment was inversely correlated with the
percentage of patients who responded to first-line (benzodiazepine) therapy
c) There is a serious risk of immediate and long-term morbidity and mortality if a convulsive seizure is not terminated by 30
minutes
d) A patient that is still seizing at presentation to the ED after receiving 2 doses of benzodiazepines in the field should
proceed to second-line agents after the appropriate time interval
e) All of the above
3) It is appropriate to order the Neuro Seizure Acute Management First Line Orders (which provides p.r.n. orders for antiepileptic medications) for all patients with a history of seizures and risk of recurrence, even if they are admitted for a nonseizure related illness (asthma, dehydration, etc)
a) True
b) False
4) Which of the following statements are TRUE regarding seizure medications?
a) Benzodiazepines are 1st line agents
b) Administer a maximum of two doses of the first-line treatment
c) Second-line therapy after benzodiazepines is fosphenytoin or phenobarbital
d) Fosphenytoin is the preferred 2nd line therapy for patients age greater than or equal to 2 months
e) Phenobarbital is preferred 2nd line therapy for patients age less than 2 months of age
f) All of the above are true
5) Which of the following is a FALSE statement regarding drug therapy for prolonged seizures?
a) Some patients with a history of frequent, prolonged and /or intractable seizures may use other agents other than
fosphenytoin or phenobarbital for their second-line treatment. Pediatric neurology should be consulted for these patients.
b) Drug therapy for prolonged seizures consists of a first line agent (benzodiazepines) and a second line agent
(fosphenytoin or phenobarbital)
c) There is no need for cardiac monitoring when administering fosphenytoin or phenobarbital
d) Benzodiazepines may be given by the nasal route if IV access is not readily available

To Self Assessment, Pg 2

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Self-Assessment
If you are taking this self-assessment as a part of required departmental training, you will need to logon to
the Learning Center to receive credit. Completion also qualifies you for 1 hour of Category II CME credit.
6) Immediate general measures for acute seizures should include:
a) Giving high-concentration oxygen
b) Assess cardiac and respiratory function
c) Check blood glucose levels
d) Securing IV access in a large vein
e) Securing airway
f) Cardiorespiratory monitoring for all patients receiving an antiepileptic medication
g) Checking blood pressures every 5 minutes during seizure and then every 10 minutes during the postictal period until
stable
h) All of the above
7) Which of the following statements is FALSE?
a) Anti-epileptic drug (AED) levels should be considered when a child with epilepsy on AED prophylaxis develops
prolonged seizure/SE.
b) In the setting of a febrile seizure, a lumbar puncture is not necessary even if the patient has meningeal signs
c) Laboratory tests (complete blood count (CBC), serum electrolytes) should be considered based on individual clinical
circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to
return to baseline alertness
d) Toxicology testing may be considered in children with prolonged seizure/SE, when no apparent etiology is immediately
identified
8) Which of the following statements regarding admission criteria are TRUE?
a) Children who are clinically unstable neurologically (e.g., not returning to baseline, very somnolent following doses of
anti-seizure medications) should be admitted for observation and support.
b) Children who present with an underlying infection requiring inpatient stay (e.g., severe pneumonia, infection requiring
intravenous antibiotics) should be admitted.
c) Children whose parents have "disabling" anxiety following the seizure episode may require admission for observation
and further parental education and reassurance.
d) Children that lack a safe home or safe transportation home require admission and may require social work consultation.
e) All of the above
9) Which of the following statements regarding nonconvulsive status epilepticus (NCSE) is TRUE?
a) In adults, NCSE is present in 14% of patients in whom convulsive SE is controlled but in whom consciousness remains
impaired.
b) Although NCSE occurs in children who present with prolonged seizure/SE, there are insufficient data to support or
refute recommendations regarding whether an EEG should be obtained to establish this diagnosis.
c) An EEG may be considered in a child presenting with prolonged seizure/SE if the diagnosis of pseudostatus epilepticus
is suspected.
d) All of the above
10) Which of the following statements is FALSE?
a) In children with prolonged seizure/SE when no apparent etiology is immediately identified, the frequency of ingestion of
a toxic substance is approximately 3.6%
b) If the patient has ingested a known toxic substance, a urine toxicology screening test is sufficient for detection
c) Neuroimaging should be considered if there is suspicion for non-accidental trauma, a focal seizure at onset, a first
seizure lasting >30 minutes, or if there is an acute change in the neurologic exam from baseline.
d) Children seizing for >40 minutes are off pathway

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Answer Key
1) The correct answer is (a), non-epileptic seizures should not be treated with benzodiazepines, or
other antiepileptic medications.
2) The correct answer is (e), all of the above statements are true.
3) The correct answer is (a). Ordering the Neuro Seizure Acute Management First Line Orders for
all patients with a history of epileptic seizures is appropriate because one should anticipate the need
for a possible seizure episode while hospitalized
4) The correct answer is (f), all of the above are true statements
5) The correct answer is (c). Cardiorespiratory monitoring is recommended when using 2nd line
agents. Fosphenytoin has direct cardiac effects which can lead to arrhythmias and phenobarbital
can cause hypotension from its vasodilatatory and cardiodepressant effects.
6) The correct answer is (h). All of the above are correct.
7) The correct answer is (b). A lumbar puncture should be performed in any child who presents with
a seizure and a fever and has meningeal signs and symptoms (e.g., neck stiffness, Kernig and/or
Brudzinski signs).
8) The correct answer is (e). All of the above statements are true.
9) The correct answer is (d). All of the above statements are true
10) The correct answer is (b). If a specific ingestion is being considered as a possible etiology of
the seizure, serum toxicology testing should be ordered. Urine toxicology screening may not be
sufficient.

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Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in
the following manner:
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Quality of Evidence:
High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394

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Summary of Version Changes

Version 1 (6/19/2012): Go live
Version 1.1 (6/24/2012): Adaptation for android use
Version 1.2 (6/11/2013): Exclusion criteria updated; patients in ICU may be on pathway at
discretion of attending MD

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Medical Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical
sciences, neither the authors nor Seattle Childrens Healthcare System nor any
other party who has been involved in the preparation or publication of this work
warrants that the information contained herein is in every respect accurate or
complete, and they are not responsible for any errors or omissions or for the
results obtained from the use of such information.
Readers are encouraged to confirm the information contained herein with other
sources.
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For questions concerning this pathway,

contact:[email protected]

Last Updated: 5/7/2012

Valid until: 5/7/2012

Bibliography
Search Methods, Seizures - Acute Management
Studies were identified by searching electronic databases using search strategies developed
and executed by a medical librarian, Jamie Graham. Searches were performed in February
2012. The following databases were searched - on the Ovid platform: Medline (2002 to date),
Cochrane Database of Systematic Reviews (2005 to date; elsewhere - Embase (2002 to
date), Clinical Evidence, National Guideline Clearinghouse, and TRIP. Retrieval was limited to
children older than neonates and English language. In Medline and Embase, appropriate
Medical Subject Headings (MeSH) and Emtree headings were used respectively, the search
strategy was adapted for other databases using their controlled vocabularies, where available,
along with text words. Concepts searched were status epilepticus. All retrieval was further
limited to certain evidence categories, such as relevant publication types, guidelines, and
index terms for study types and other similar limits.
Jamie Graham, MLS
June 1, 2012

Identification
1 additional record identified
through other sources
7 studies added from Febrile Seizure Pathway

64 records identified through

database searching

Screening
62 records after duplicates removed

62 records screened

24 records excluded

38 full-text articles assessed for eligibility

34 full-text articles excluded,

1 did not answer clinical question
7 older study
26 did not meet quality threshold

Elgibility

Included
11 studies included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535
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Bibliography
(AAP), Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child
with a simple febrile seizure. Pediatrics [IBD]. 2011;127(2):389-394.
Baumer, JH. (2004). Evidence based guideline for post-seizure management in children presenting acutely to
secondary care. Arch Dis Child; 89:278-280.

(BC), Febrile seizures. (2010). Clinical Practice Guidelines and Protocols in British Columbia
Batra, P., Gupta, S., Gomber, S., & Saha, A. (2011). Predictors of meningitis in children presenting with first febrile
seizures. Pediatric Neurology, 44(1), 35-39.
Fetveit, A. (2008). Assessment of febrile seizures in children. European Journal of Pediatrics, 167(1), 17-27.
Harden, C., Huff,J., Schwartz,T., et.al. ((2007). Reassessment: Neuroimaging in the emergency patient presenting
with seizure (an evidence-based review). Neurology 2007;69:1772-1780.

Kimia, A., Ben-Joseph, E. P., Rudloe, T., Capraro, A., Sarco, D., Hummel, D., et al. (2010). Yield of lumbar
puncture among children who present with their first complex febrile seizure. Pediatrics, 126(1), 62-69.
Ma, L., Yung, A., Kwong, K., et al. (2010). Clinical Guidelines on Management of Prolonged Seizures, Serial
Seizures and Convulsive Status Epilepticus in Children. HK J Paediatr (new seeries) 2010; 15: 52-63.
NICE clinical guideline 137 (2012). The epilepsies: the diagnosis and management of the epilepsies in adults and
children in primary and secondary care. www.nice.org.uk/cg137
Riviello, JJ., Ashwal,S., Hirtz, D., et. al. (2006). Practice Parameter: Diagnostic assessment of the child with
status epilepticus (an evidence-based review). Neurology 2006;67:1542-1550.
Seltz LB, Cohen E, Weinstein M. Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with
complex febrile seizures. Pediatr Emerg Care. 2009;25(8):494-497

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