While many of the causes and types of seizures in children are similar to adults, some differences exist in etiologies, manifestations, and responses to antiepileptics. Many of these differences are accounted for by factors related to the developing brain of a child.1 For example, certain considerations with respect to seizure are unique to children, such as febrile seizure and factors related to underlying metabolic disease, genetic predisposition, or neurovascular anatomy. Other factors unique to children are trauma (non-accidental) and ingestion. This article is written as a pediatric supplement to a recent ACEP Now article entitled, “Tips for Managing Active Seizures in the Emergency Department” by Anton Helman, MD, CCFP(EM), FCPP. 

Seizure is one of the most common neurologic emergencies in children.2 For a parent, witnessing a child’s  seizure can be distressing and therefore a call to 9-1-1 may ensue. Status epilepticus (currently defined as a seizure that lasts more than five minutes, or a series of two or more shorter seizures without return to baseline) is a true medical emergency.3 The definition of status epilepticus (International League Against Epilepsy) was recently modified to highlight the recent understanding that irreversible neurologic damage occurs faster than previously thought and for the purpose of intervening urgently, the previous duration of 15 minutes was shortened to five minutes. For this reason, refractory seizure, which is associated with irreversible neurologic damage, is defined as convulsive seizure lasting more than 30 minutes.3

Similar to adults, the most common emergency department (ED) presentation of status epilepticus is convulsive type (also known as tonic-clonic type). Seizures lasting more than 30 minutes have been associated with poor outcomes, higher likelihood of complications, and are considered refractory. Children younger than two years old and those with febrile seizures are at greater risk for status epilepticus. Most causes of status epilepticus remain unknown, however, febrile seizure is likely the most common cause of status epilepticus in children six months to five years.^{4, 5}

The goal of therapy is to stop seizures as quickly as possible, because the longer the seizure continues the more challenging it becomes to stop it successfully.6  In addition to this, prevention of recurrence is also a desired goal.6

Considerations for Pediatric Seizures:⁷ 

• Duration of seizure
• Type of seizure (convulsive or non-convulsive)
• Preceding intervention (e.g., rectal diazepam administered by parent/caregiver or medication administered by prehospital providers)
• Any prior seizure history
• Presence of fever within the previous 24 hours of the seizure
• Any medical history that increases seizure risk
• Trauma or possible ingestion
• Electrolytes (glucose, calcium, sodium, and magnesium)
• Presence of hypo- or hyperthermia

Attention to potential underlying cause of seizure is an important part of seizure management.⁷ In children, ingestion and trauma (intentional or accidental) also need to be considered. In smaller children, undiagnosed metabolic disease and structural brain abnormalities should also be considered.