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Emergency and Acute Medicine - Seizure (Pediatric)
Seizures in children are defined as sudden, abnormal discharges of neurons that result in a change in behavior or neurologic function. They can occur across all pediatric age groups, from neonates to adolescents, and have a wide range of causes. Common etiologies include febrile seizures, infections, trauma, metabolic disturbances such as hypoglycemia or electrolyte abnormalities, toxicologic causes including drug ingestion or withdrawal, congenital or structural brain abnormalities, perinatal hypoxia, intracranial hemorrhage, degenerative diseases, and psychogenic causes.
Clinical presentation varies by age. In neonates, seizures may be subtle and difficult to recognize, often presenting as repetitive facial movements, eye deviation, eyelid fluttering, lip smacking, sucking motions, or respiratory changes such as apnea. Seizures in this group may be focal or generalized and can include tonic, clonic, or myoclonic movements. Interestingly, generalized systemic problems such as metabolic disturbances or infections may still present with focal seizure activity in neonates.
In older infants and children, seizures are more recognizable and can be classified as generalized or focal. Generalized seizures include tonic–clonic, tonic, clonic, myoclonic, atonic (“drop attacks”), and absence seizures. Focal (partial) seizures may be simple, where consciousness is preserved, or complex, where consciousness is impaired. Simple focal seizures may involve motor, sensory, or cognitive symptoms such as localized jerking, paresthesias, or hallucinations. Complex focal seizures often begin with an aura followed by altered consciousness and may progress to generalized seizures. Status epilepticus, defined as prolonged or recurrent seizures without recovery, is most commonly generalized but may also be focal or present as persistent altered mental status.
A thorough history is critical and should determine whether the seizure was febrile or afebrile, the type and duration of seizure, associated features such as aura, cyanosis, or eye deviation, and the presence of a postictal state. Family history and predisposing conditions should also be explored. Physical examination must include vital signs, especially temperature, and a detailed neurologic assessment, including mental status. Examination of the eyes and skin is important to identify underlying conditions such as neurocutaneous syndromes (e.g., tuberous sclerosis).
Evaluation begins with a bedside glucose measurement, especially in infants and in status epilepticus. Additional laboratory studies such as electrolytes, renal function, calcium, magnesium, complete blood count, and toxicology screening should be guided by clinical findings. In children already on anticonvulsants, drug levels should be checked. Imaging with head CT is indicated in cases of focal seizures, new neurologic deficits, suspected intracranial hemorrhage, or new-onset status epilepticus without a clear cause. Lumbar puncture is indicated if meningitis or encephalitis is suspected, but neuroimaging should precede it if there are signs of increased intracranial pressure. MRI is rarely required emergently. EEG is generally useful in afebrile seizures to help classify seizure type and assess recurrence risk but is not typically helpful in the acute setting.
Management focuses first on stabilization of airway, breathing, and circulation. Oxygen should be administered, and pulse oximetry monitoring initiated. A nasopharyngeal airway is preferred over an oral airway, and bag-valve-mask ventilation should be used if the child is hypoventilating or hypoxic. Intubation may be required if seizures are refractory or ventilation is inadequate. Intravenous access should be established, and hypoglycemia corrected promptly with dextrose. Spine precautions should be maintained if trauma is suspected.
Active seizures, particularly status epilepticus, require prompt pharmacologic treatment. Benzodiazepines such as lorazepam are first-line due to their rapid onset and longer duration of action. If intravenous access is not available, alternatives include buccal midazolam, intranasal lorazepam, or rectal diazepam. If seizures persist, second-line agents such as phenytoin or fosphenytoin are used for longer-term control. Phenobarbital may be administered if seizures are refractory, although there is an increased risk of respiratory depression, especially when combined with benzodiazepines. In refractory status epilepticus, advanced therapies such as barbiturate coma or general anesthesia may be required, with continuous EEG monitoring to confirm seizure suppression. In neonates, phenobarbital is often the preferred first-line and maintenance therapy.
Disposition depends on the clinical scenario. Children with ongoing status epilepticus, persistent altered mental status, or requiring intubation should be admitted to the intensive care unit. Those with resolved status epilepticus but unclear or serious underlying causes should be admitted for further evaluation. Discharge may be appropriate if the child has returned to baseline mental status, has a normal neurologic examination, no serious underlying cause is identified, and reliable caregivers are available.
Follow-up includes providing seizure precautions, education for caregivers, and arranging evaluation with a primary care physician or pediatric neurologist. Important clinical points include recognizing that many conditions can mimic seizures, ensuring early treatment of prolonged seizures to reduce morbidity, and considering alternative routes of benzodiazepine administration when intravenous access is not available.
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