Seizures in Children
                             ====================
þ Neonatal Seizures:
 - Pyridoxine, 100 mg intravenously, should be considered for neonates with 
   intractable seizures of unclear etiology
   [Kwon KT, Tsai VW. Metabolic emergencies. Emergency medicine clinics of 
   North America 2007;25:1041-60, vi.]

þ Febrile Seizures:
  <FebSeize.txt>

þ American Academy of Neurology Clinical Practice Guidelines:
  (for common ED seizures)
 - < 6 months: admit, consult neuro
 - > 6 months:
  + check glucose
  + tox screen, electrolyes: only if clinical suspicion
  + EKG: ? not in practice guidelines, but often done; most with cardiac
    syncope don't have prolonged tonic-clonic true seizure, do only if question
    of cardiac syncope
  + EEG: have PCP schedule as outpatient
  + CT? 5-10% will have some abnormality, 33% if get MRI, but few influence
    management.
     - CT if:
      Todd's paralysis
      focal seizure < 3 years
      persistent MS changes
      predisposing factors:
        sickle, bleeding problems
        CNS disease, malignancy
        HIV, hemihypertropy
        hydrocephalus, travel to cysticercosis
        closed head injury

þ New afebrile seizure:
 + In most cases, don't need to start anticonvulsant right away;
 + don't need to get CT scan if patient looks OK.
 + 50% of normal looking kids will not have a second seizure;
 + it's hard to take kids off an anticonvulsant.
 + If second seizure, go ahead and start anticonvulsant.

þ Seizure 3 days later:  just admit.

þ IM Versed
 - For kids with seizures, IM Versed worked better than IV Valium
   <Versed.TXT - Chamber>
 - Midazolam  0.2 mg/kg (max 7 mg) IM
 
þ History:  Was it really a seizure? What kind of seizure was it?

þ Presentations:
 - Febrile Seizure <FebSeize.TXT>
 - Afebrile Seizure (recent or remote)
 - Status Epilepticus
 - Breakthrough Seizure in Patient with Known Seizures.

þ Classsify seizure:
 - Partial; Generalized; Unclassifies; Status Epilepticus.
 - Partial:
  + Simple (consciousness preserved)
  + Complex (consciousness impaired)
  + (either may generalize)
  + (Complex may have staring, amnesia, automatisms,
 - Generalized:
  + Absence ("Petit Mal") 10-20 sec.
  + Tonic-Clonic ("Grand Mal")
  + Myoclonic ("Minor Motor") brief shock-like motor twitches,
    usually bilaterally; more often than normal myoclonic jerks
 - Non-Epileptic seizures:
  + Anoxia (faints, febrile syncope, breath-holding)
  + Apnea or Bradycardia in infants
  + Paroxysmal Vertigo
   - ?migraine equivalent;
   - run to and hug parents tightly;
   - may see nystagmus;
   - resolves in minutes;
   - toddlers to 7-8 years age group?
   - +FH of migraine helpful in diagnosis)
 - Psychiatric
  + hyperventilation;
  + pseudoseizures:
  + avoid eye contact, hold eyes shut;
  + very atypical movements;
  + usually have severe psychiatric illness
 - Migraine or similar Periodic Syndromes
  + Tics and other abnormal movements (most disappear during sleep)
 - Paroxysmal Nocturnal Events:
  + night terrors,
  + somnambulism,
  + abnormal  movements during sleep;
  + narcoplepsy;
  + cataplexy;
  + sleep paralysis;
  + hypnagogic/hypnopompic hallucinations

þ Precipitant Drugs for Pediatric Seizures:
 - adrenergics,
 - sedative withdrawal,
 - phenothiazines,
 - tricyclics

þ Drugs:
 - Current Fad:  MONOTHERAPY push levels of a single drug for monotherapy
 - phenobarb:
  + 20mg/kg IV; or
  + PO twice maintenance for 3 days.
  + Maint 5mg/kg/day
 - Dilantin (phenytoin):
  + 20mg/kg IV; or,
  + 20 mg/kg divided into 2-5 hourly doses 1 mg/kg/min infusion
 - lorazepam (Ativan):
  + onset 2-20 minutes, duration 2-4 hours;
  + 0.05-.01 mg/kg IV (Max 4-8mg); or,
  + 0.05-0.15 mg/kg SL; or,
  + 0.05 mg/kg rectal
 - Valium:
  + .5-1.0 mg/kg IV solution rectal;
  + useful for home for preventing febrile seizures
 - Paraledehyde:
  + good IV 200mg/kg loading via 4% solution IV 200 mg/kg/hr;
  + good level is 300 mg
 - valproate (valproic acid/depakene):
  + may load with 60/mgkg/day rectal with depakene syrup in cocoa butter;
  + may cause hepatic toxicity in children;
  + causes N/V/anorexia, easy bruising;
  + may get breakthrough from hepatic toxicity
 - Tegretol (carbemazapine):
 + thrombocytopenia and neutropenia significant side effects;
 + get baseline in ED if starting in ED.
 - Pyridoxine:
  + 25 - 50 mg of should be administered intravenously in neonatal seizures
    as some neonates will have seizures secondary to a syndrome of pyridoxine
    dependence (a metabolic disorder requiring lifelong pyridoxine therapy).
  + Tintinalli 3rd ed. p 480-1, Schwartz 3rd ed. p 364.

þ Choice of Anticonvulsant for Pediatric Seizures:
 - Abscence:
  + Valproate (depakene)/
  + ethosuximide
    (Tegretol known for worsening of abscence episodes.)
 - Tonic-clonic:
  + Dilantin/
  + Phenobarb
 - Partial:
  + Dilantin/
  + Tegretol (carbamezapine)
 - Myotonic/Atonic:
  + benzodiazepines
 - Neonatal:
  + lorazepam (Ativan) is preferred over diazepam (Valium) when using a
    benzodiazepine to control neonatal seizures in a jaundiced baby;
    Diazepam uncouples the bilirubin-albumin complex and may worsen
    hyperbilirubinemia.  Ref: Tintinalli 3rd ed. p 481
  + pyridoxine; see above <N-seizure.TXT -pyridoxine>
 - Febrile: see <FebSeize.TXT>

þ Status Epilepticus (may also be ascence or partial status epilepticus)
  After 60 minutes (or a bit more in children), permanent damage.
  0-5 minutes: ABC's, look for trauma, infection, good IV access
  6-9 minutes: give glucose and B vitamins
  10-30 minutes:  Dilantin, benzodiazepine, or phenobarb.
  Dilantin preferred in kids: fast response, goes through BBB, doesn't cause CNS
    depression; if that doesn't work, try .1mg/kg bolus of lorazepam x2; then
    phenobarb; then general anaesthesia.

þ Breakthrough Seizure:
 + check levels,
 + look for trauma,
 + do tox screen,
 + check routine labs including Mg, PO4, Ca, lytes/BUN/Cr/Glucose