5. PEDIATRIC EMERGENCIES
5.7 PEDIATRIC SEIZURES
A seizure is a temporary alteration in behavior due to the massive electrical discharge of one or more groups of neurons in the brain. Seizures can present in several different forms: generalized or grand mal seizure, partial -simple, partial-complex or petit mal seizure. The single most common cause of seizure disorder is idiopathic epilepsy. However, there are multiple other causes: hypoglycemia, head trauma, vascular disorders, meningitis, sepsis, metabolic abnormalities, poisoning, hypoxemia, tumors, and shock. The seizure may be followed by postictal state or complete coma depending upon cause. The most common cause of seizure in children age 1 - 4 is "benign febrile seizure". These seizures usually last less than 5 minutes and are tonic-clonic and nonfocal.
ASSESSMENT/TREATMENT PRIORITIES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated.
3. Administer high concentration of oxygen via non-rebreather mask once seizure has abated. Be certain that the oropharynx is clear of secretions and/or vomitus.
4. Obtain appropriate history related to event, including Past Medical History, Medications, Drug Allergies and Substance Abuse including possible ingestion or overdose of medications.
5. Question all witnesses or bystanders as to actual event.
6. The majority of seizures are self- limiting, followed by a gradual awakening. However, prolonged or recurrent seizures may indicate status epilepticus.
TREATMENT
BASIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. (In case of suspected head/neck injury, assure cervical spine immobilization.)
3. Administer high concentration of oxygen via non-rebreather mask once seizure has abated and assist ventilations as needed
4. Prevent the patient from harming his or herself. Place patient in left lateral recumbent position.
5. DO NOT use a bite block.
6. Activate ALS intercept if deemed necessary and if available.
7. Initiate transport as soon as possible with or without ALS.
8. Monitor vital signs en route to the hospital
9. Notify receiving hospital.
INTERMEDIATE PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. (In case of suspected head/neck injury, assure cervical spine immobilization.)
3. Administer high concentration of oxygen via non-rebreather mask once seizure has abated and assist ventilations as needed
4. Prevent the patient from harming his or herself. Place patient in left lateral recumbent position.
5. Do NOT use a bite block.
6. Activate Paramedic intercept, if deemed necessary and if available.
7. ALS STANDING ORDERS
a. Provide advanced airway management if indicated.
b. Initiate IV Normal Saline (KVO), while en-route to hospital, if vein is visible and/or palpable.
8. Initiate transport as soon as possible with or without Paramedics.
9. Continue monitoring vital signs en route to the hospital.
10. Notify receiving hospital.
PARAMEDIC PROCEDURES
1. Maintain universal blood and body fluid precautions.
2. Maintain an open airway and assist ventilations as needed. This may include repositioning of the airway, suctioning to remove secretions and/or vomitus, or use of airway adjuncts as indicated. (In case of suspected head/neck injury, assure cervical spine immobilization.)
3. Administer high concentration of oxygen via non-rebreather mask once seizure has abated and assist ventilations as needed
4. Prevent the patient from harming his or herself. Place patient in left lateral recumbent position.
5. DO NOT use a bite block.
6. ALS STANDING ORDERS
a. Provide advanced airway management, if indicated.
b. Initiate IV Normal Saline (IV), in visualized or palpated vein.
c. Cardiac Monitor: manage dysrhythmias per protocol.
d. Determine Blood Glucose level with Dextrose stick.
- If Glucose is greater than 100 mg/dL, glucose administration unnecessary.
- If Glucose is less than 100 mg/dL, administer:
- i. Dextrose 10% 0.5 gm/kg IV Bolus (for neonates)
- ii. Dextrose 25% 0.5 gm/kg IV Bolus (if estimated body weight is less than 50 kg)
- iii. Dextrose 50% 0.5 gm/kg IV Bolus (if estimated body weight is greater than 50 kg)
e. Naloxone HCL
- i. If age less than 5 years: 0.1 mg/kg to max. dose of 2.0 mg IV Bolus,
- ET, IM, SQ or IO
- ii. If age 5 years or greater: 2.0 mg IV Bolus, ET, IM, SQ or IO
- NOTE: If given via ET, follow with 2.0 ml sterile Normal Saline solution.
7. Initiate transport as soon as possible.
8. Contact MEDICAL CONTROL. The following may be ordered:
a. For status epilepticus:
- Valium (Diazepam) 0.25 mg/kg , IV, IO to maximum single dose of 5-10 mg.* RECTAL DOSE: 0.5 mg/kg
- Ativan (Lorazepam) 0.05-0.2 mg/kg IV, IO slowly (dilute 1:1 in Normal saline) or IM to maximum single dose of 2-4 mg*
- Additional IV Dextrose per above protocol.
- Additional Narcan (Naloxone) per above protocol.
- Normal Saline fluid challenge, if indicated 10-20 ml/kg
* Valium (Diazepam) and Ativan (Lorazepam) should be used to treat only those children who suffer continuous tonic/clonic seizure activity for more than 30 minutes and who demonstrate signs of inadequate oxygenation, such as cyanosis. Apnea often follows intravenous administration of Diazepam; accordingly, field personnel should carefully monitor respiration and prepare to support ventilation with bag-valve-mask apparatus following administration of this agent.
NOTE: Valium and/or Ativan are CONTRAINDICATED in patients with head injury or hypotension.
MoonDragon's EMS Index Page
HELPFUL PRODUCTS & FURTHER EDUCATION
-- by Phyllis A. Balch, James F. Balch - 2nd Edition
-- by Phyllis A. Balch, James F. Balch - 4th Edition
-- by Phyllis A. Balch
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