Management of Seizures in Pediatric Patients
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Emergency Department Management Of Seizures In Pediatric Patients

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Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal Of The Literature
  5. Etiology And Pathophysiology
  6. Differential Diagnosis
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. History
    2. Physical Examination
  9. Diagnostic Studies
    1. Simple Febrile Seizures
      1. Lumbar Puncture
        • What Are The Current Guidelines For Performing A Lumbar Puncture For A Febrile Seizure?
      2. Other Testing For Serious Bacterial Illness
      3. Electrolyte Panels
      4. Neuroimaging
      5. Electroencephalography
    2. Complex Febrile Seizures
      1. Lumbar Puncture
      2. Other Testing For Serious Bacterial Illness
      3. Neuroimaging
      4. Electroencephalography
    3. First Nonfebrile/Unprovoked Seizure
      1. Lumbar Puncture
      2. Electrolyte Panels
      3. Toxicology Screening
      4. Neuroimaging
      5. Electroencephalography
    4. Status Epilepticus
      1. Lumbar Puncture
      2. Other Testing For Serious Bacterial Illness
      3. Electrolyte Panel
      4. Toxicology Screening
      5. Neuroimaging
      6. Electroencephalography
    5. Known Seizure Disorder/Epilepsy
      1. Laboratory Testing
      2. Neuroimaging
  10. Treatment
    1. Airway
    2. Anticonvulsant Medications
      1. Benzodiazepines
      2. Hydantoins
      3. Barbiturates
      4. Valproic Acid
      5. Levetiracetam
      6. Lacosamide
      7. Carbamazepine And Related Drugs
      8. Propofol Infusion
  11. Status Epilepticus
  12. Special Populations
    1. Neonatal Seizures
    2. Seizures Due To Toxic Ingestions
    3. Posttraumatic Seizures
  13. Controversies and Cutting Edge
    1. Intravenous Levetiracetam For Status Epilepticus
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls In The Management Of Seizure Disorders In Pediatric Patients
  17. Time- And Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway For Emergency Department Management Of Pediatric Status Epilepticus
  20. Clinical Pathway For Emergency Department Management of Neonatal Status Epilepticus
  21. Tables and Figures
    1. Table 1. Seizure Mimics
    2. Table 2. Life-Threatening Causes Of Seizure
    3. Table 3. Summary Of Recommendations For Diagnostic Studies For Seizure Disorders
  22. References

Abstract

Seizures account for 1% of all emergency department visits for children, and the etiologies range from benign to life-threatening. The challenge for emergency clinicians is to diagnose and treat the life-threatening causes of seizures while avoiding unnecessary radiation exposure and painful procedures in patients who are unlikely to have an emergent pathology. When treating patients in status epilepticus, emergency clinicians are also faced with the challenge of choosing anticonvulsant medications that will be efficacious while minimizing harmful side effects. Unfortunately, evidence to guide the evaluation and management of children presenting with new and breakthrough seizures and status epilepticus is limited. This review summarizes available evidence and guidelines on the diagnostic evaluation of first-time, breakthrough, and simple and complex febrile seizures. Management of seizures in neonates and seizures due to toxic ingestions is also reviewed.

Keywords: emergency medicine CME, seizure, simple febrile seizure, complex febrile seizure, nonfebrile seizure, unprovoked seizure, status epilepticus, epilepsy, lumbar puncture, electrolyte panels, neuroimaging, electroencephalography, toxicology screening, benzodiazepines, lorazepam, midazolam, diazepam, hydantoins, phenytoin, fosphenytoin, barbiturate, valproic acid, levetiracetam, lacosamide, propofol, carbamazepine, oxcarbazepine, eslicarbazepine, pyridoxine

Case Presentations

You are working a busy morning shift with a new medical student. You are reviewing the nursing notes for the 12-year-old boy who had a 2-minute generalized tonic-clonic seizure just after waking up. Just then, a 7-month-old girl is rushed in by panicked parents who say they were driving near the hospital when their daughter became unresponsive and was shaking in all her extremities for 1 minute. By the time you see her, she is awake and alert, and only wants to be held by her mother. Her temperature in triage is 40.5˚C. Your charge nurse comes to tell you that an ambulance is bringing in a 6-year-old boy with a known seizure disorder who is actively seizing. You ask the triage nurse to give the 7-month-old acetaminophen while you prepare for the 6-year-old patient. As you are running through medication dosing in for the 6-year-old, the medical student asks what laboratory tests you would order for each patient and if he should call for a CT scan for any of the patients…

Introduction

Seizures account for 1% of all emergency department (ED) visits for patients aged < 18 years and account for an even higher percentage of visits in some tertiary referral hospitals.1,2 Each year, approximately 25,000 to 40,000 children in the United States experience their first nonfebrile seizure.3,4 Seizures are especially common in infants and children aged < 5 years.1 Infants aged < 1 year have the highest incidence of new unprovoked seizures in any age group.5 Seizures present special diagnostic and treatment challenges because the etiologies of seizures range from benign to life-threatening. Evaluation and treatment of seizures must be individualized based on the patient's presentation and the likely etiology. Management of a patient in status epilepticus requires simultaneous attention to respiratory and circulatory status, vascular access, and investigation into and treatment of reversible or life-threatening causes of seizure. However, well-appearing patients with self-resolved recurrent seizures or simple febrile seizures may not require any further investigation after a reassuring history and physical examination is completed. Unnecessary laboratory testing and radiation exposure should be avoided in these patients.

Critical Appraisal Of The Literature

A literature search was performed in PubMed using combinations of the search terms pediatric, child, children, neonatal, neonate, seizure, febrile seizure, complex febrile seizure, status epilepticus, neuroimaging, and anticonvulsant. The references of articles were reviewed to identify relevant publications. The National Guideline Clearinghouse and the Cochrane Library were also searched.

Searches of the clinical policies and guidelines of the American Academy of Pediatrics (AAP), the American College of Emergency Physicians (ACEP), the American Academy of Neurology (AAN), the Child Neurology Society, and the American Epilepsy Society were conducted. The only relevant ACEP clinical policy was a 2014 policy on evaluation and management of seizures in adults. Applicable AAP clinical policies dealt only with febrile seizures. Available guidelines do not address many questions that arise in the evaluation and treatment of seizures. Specific issues not addressed in published guidelines are the appropriate evaluation of complex febrile seizures and the role of newer anticonvulsants (such as levetiracetam) in the ED setting.

Risk Management Pitfalls In The Management Of Seizure Disorders In Pediatric Patients

1. "I didn't think to check the patient's blood sugar. The patient isn't diabetic, and I was focused on stopping the seizure and managing the airway.”

Hypoglycemia is a dangerous but reversible cause of seizures. Children may be hypoglycemic for a number of reasons such as ingestion of oral hypoglycemic medications and undiagnosed metabolic disorders. A bedside glucose level should be checked immediately in patients with active seizures or altered mental status.

2. "I didn't consider eclampsia as a cause of seizures. The patient is only 14 years old.”

While rare in pediatric patients, eclampsia cannot be missed, as this diagnosis changes patient management drastically. For additional information on management of this condition, refer to the January 2015 Emergency Medicine Practice issue titled "Clinical Decision Making In Seizures And Status Epilepticus," available at: www.ebmedicine.net/EMPseizures.

3. "The 3-month-old girl had a single, brief, self-resolved generalized seizure. She looked great, so I diagnosed her with a simple febrile seizure.”

Febrile seizures are seen in children aged 6 months to 5 years. A fever and seizure in a younger infant is concerning for infections such as meningitis and encephalitis.

4. "I thought febrile seizures were a benign entity, so I didn't work up the 18-month-old child for meningitis.”

While simple febrile seizures are generally a benign entity, not all seizures associated with fever are febrile seizures. Encephalitis, brain abscess, and meningitis may all present with fever and seizure. While the vast majority of children with simple febrile seizures do not require a lumbar puncture, a careful history and physical examination is needed to evaluate for signs and symptoms of serious infection or other serious pathology.

5. "Witnesses said the patient had a seizure at school. I worked him up for a first-time seizure, but didn't see any reason to get an ECG.”

Dysrhythmia leading to syncope is a dangerous seizure mimic. Patients with a dysrhythmia may have twitching motions that are mistaken for seizure activity.

6. "I know chemistries are generally normal in seizure patients, so I didn't order one for the seizing 3-week-old.”

While electrolytes are likely to be normal in an older infant or child with a self-resolved seizure, status epilepticus in any child, or even a resolved seizure in a neonate, warrants further investigation. A neonate may have hypocalcemia due to undiagnosed DiGeorge syndrome or hyponatremia or hypernatremia from improper formula preparation.

7. "The pediatric neurologist said I should have given pyridoxine to the neonate with status epilepticus. I'd never even heard of pyridoxine-dependent seizures.”

Pyridoxine-dependent seizures are a diagnosis unique to pediatric patients. Pyridoxine should be administered to infants with seizures that do not resolve with first-line treatments.

8. "The pediatric intensive care unit attending just told me that I should have treated the 2-year-old in status epilepticus with pyridoxine because it turned out the child ingested isoniazid. I never thought to ask about isoniazid in the home.”

Isoniazid overdose and several other ingestions can cause seizures that are unlikely to be controlled with other treatments. Pyridoxine should be considered for difficult-to-control and otherwise unexplained seizures.

9. "I asked about a history of trauma in the baby, but the family denied it. They seemed trustworthy.”

Unfortunately, one diagnosis that must always be a consideration in pediatric patients is nonaccidental trauma, and caregivers are unlikely to volunteer this information or provide a reliable history.

10. ”I'm being sued because a teenager I saw for a first-time seizure was in a car accident during a second seizure and injured several people. I always report adults with seizures to the Department of Motor Vehicles, but I didn't know this teenager even had a driver's license."

Clinicians must report patients with seizures in some states. It is prudent to understand the laws of the state and remember that older teenagers are of driving age.

Tables and Figures

Table 1. Seizure Mimics

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. Pallin DJ, Goldstein JN, Moussally JS, et al. Seizure visits in US emergency departments: epidemiology and potential disparities in care. Int J Emerg Med. 2008;1(2):97-105. (Retrospective review; based on 11 years of National Hospital Ambulatory Medical Care Survey data)
  2. Sharma S, Riviello JJ, Harper MB, et al. The role of emergent neuroimaging in children with new-onset afebrile seizures. Pediatrics. 2003;111(1):1-5. (Retrospective study; 500 pediatric patients)
  3. * Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society. Neurology. 2000;55(5):616-623. (Practice guideline)
  4. Hauser W, Annegers J, Kurland L. Incidence of epilepsy and unprovoked seizures in Rochester, Minnesota: 1935-1984. Epilepsia. 1993;34(3):453-468. (Population-based study)
  5. Olafsson E, Ludvigsson P, Gudmundsson G, et al. Incidence of unprovoked seizures and epilepsy in Iceland and assessment of the epilepsy syndrome classification: a prospective study. Lancet Neurol. 2005;4(10):627-634. (Prospective population-based study using a nationwide surveillance system)
  6. Hauser WA, Beghi E. First seizure definitions and worldwide incidence and mortality. Epilepsia. 2008;49(Supple 1):8-12. (Review)
  7. * Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. (Guideline)
  8. Lowenstein DH, Bleck T, Macdonald RL. It's time to revise the definition of status epilepticus. Epilepsia. 1999;40(1):120- 122. (Expert opinion)
  9. Guidelines for epidemiologic studies in epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. 1993;34(4):592-596. (Guideline)
  10. Shinnar S, Berg AT, Moshe SL, et al. How long do new-onset seizures in children last? Ann Neurol. 2001;49(5):659-664. (Prospective study; 407 pediatric patients)
  11. Carreno M. Recognition of nonepileptic events. Semin Neurol. 2008;28(3):297-304. (Review)
  12. Joyce SM, Brown DE, Nelson EA. Epidemiology of pediatric EMS practice: a multistate analysis. Prehosp Disaster Medicine. 1996;11(3):180-187. (Prospective study; 61,132 EMS calls for pediatric patients)
  13. Richard J, Osmond MH, Nesbitt L, Stiell IG. Management and outcomes of pediatric patients transported by emergency medical services in a Canadian prehospital system. Can J Emerg Med. 2008;8(1):6-12. (Prospective study; 1377 EMS calls for pediatric patients)
  14. Bosson N, Santillanes G, Kaji AH, et al. Risk factors for apnea in pediatric patients transported by paramedics for out-of-hospital seizure. Ann Emerg Med. 2014;63(3):302-308. (Retrospective study;1584 pediatric patients)
  15. Alldredge BK, Gelb AM Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus. N Engl J Med. 2001;345(9):631-637. (Prospective randomized double-blind trial; 205 adults)
  16. * Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591-600. (Prospective randomized double-blind noninferiority trial; 893 pediatric and adult patients)
  17. * Prasad M, Krishnan PR, Sequira R, et al. Anticonvulsant therapy for status epilepticus. Cochrane Database Syst Rev. 2014;9:CD003723. (Systematic review)
  18. Arya R, Gulati S, Kabra M, et al. Intranasal versus intravenous lorazepam for control of acute seizures in children: a randomized open-label study. Epilepsia. 2011;52(4):788-793. (Prospective randomized open-label study; 141 pediatric patients)
  19. Wermeling DPH, Miller JL, Archer SM, et al. Bioavailability and pharmacokinetics of lorazepam after intranasal, intravenous, and intramuscular administration. J Clin Pharmacol. 2001;41(11):1225-231. (Prospective randomized cross-over study; 11 adults)
  20. Medical Services Commission. Febrile seizures. Victoria (BC): British Columbia Medical Services Commission. 2010 Sept 1. Available at: http://www.guideline.gov/content.aspx?id=38901&search=febrile+seizure Accessed September 25, 2014. (Guideline)
  21. Capovilla G, Mastrangelo M, Romeo A, et al. Recommendations for the management of "febrile seizures”: ad hoc task force of LICE Guidelines Commission. Epilepsia. 2009;50(Suppl 1):2-6. (Practice guideline)
  22. Warden CR, Zibulewsky J, Mace S, et al. Evaluation and management of febrile seizures in the out-of-hospital and emergency department settings. Ann Emerg Med. 2003;41(2):215-222. (Review)
  23. Oluwabusi T, Sood SK. Update on the management of simple febrile seizures: emphasis on minimal intervention. Curr Opin Pediatr. 2012;24(2):259-265. (Review)
  24. Peltola H, Kilpi T, Anttila M. Rapid disappearance of Haemophilus influenzae type b meningitis after routine childhood immunisation with conjugate vaccines. Lancet. 1992;340 (8819):592-4. (Population-based study)
  25. Whitney CG, Ferley MM, Hadler J, et al. Decline in invasive pneumococcal disease after the introduction of protein-polysaccharide conjugate vaccine. N Engl J Med. 2003;348 (18):1737-1746. (Population-based study; 16 million people)
  26. Kyaw MH, Lynfield R, Schaffner W, et al. Effect of introduction of the pneumococcal conjugate vaccine on drug-resistant Streptococcus pneumoniae. N Engl J Med. 2006;354(14):1455- 1463. (Population-based study)
  27. Green SM, Rothrock SG, Clem KJ, et al. Can seizures be the sole manifestation of meningitis and febrile children? Pediatrics. 1993; 92(4):527-534. (Retrospective case series; 503 pediatric patients)
  28. Trainor JL, Hampers LC, Krug SE, et al. Children with first time simple febrile seizures are at low risk of serious bacterial illness. Acad Emerg Med. 2001;8(8):781-787. (Retrospective cohort study; 455 pediatric patients)
  29. Horn J, Medwid K. The low rate of bacterial meningitis in children, ages 6-18 months, with simple febrile seizures. Acad Emerg Med. 2011;18(11):1114-1120. (Review)
  30. Kimia AA, Capraro AJ, Hummel D, et al. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6-12. (Retrospective cohort study; 704 pediatric patients)
  31. Batra P, Gupta S, Gomber S, et al. Predictors of meningitis in children presenting with first febrile seizures. Pediatr Neurol. 2011;44(1):35-39. (Retrospective study; 497 pediatric patients)
  32. Teach SJ, Geil PA. Incidence of bacteremia, urinary tract infections, and unsuspected bacterial meningitis in children with febrile seizures. Pediatr Emerg Care. 1999;15(1):9-12. (Retrospective study; 218 pediatric patients)
  33. Teran CG, Medows M, Wong SH, et al. Febrile seizures current role of laboratory investigations and source of the fever in the diagnostic approach. Pediatr Emerg Care. 2012;28 (6):493-497. (Retrospective review; 219 pediatric patients, 125 with simple and complex febrile seizures)
  34. Jaffe M, Bar-Joseph G, Tirosh E et al. Fever and convulsions–indications for laboratory investigations. Pediatrics. 1981;67(5):729-731. (Retrospective study; 323 pediatric patients with simple febrile seizures)
  35. Nypaver MM, Reynolds SL, Tanz RR, et al. Emergency department laboratory evaluation of children with seizures: dogma or dilemma? Pediatr Emerg Care. 1992;8(1):13-16. (Retrospective study; 108 pediatric patients with simple febrile seizures)
  36. Kenney RD, Taylor JA. Absence of serum chemistry abnormalities in pediatric patient's presenting with seizures. Pediatr Emerg Care. 1992;8(2):65-66. (Retrospective study; 193 pediatric patients, 74 with febrile seizures)
  37. Scarfone RJ, Pond K, Thompson K, et al. Utility of laboratory testing for infants with seizures. Pediatr Emerg Care. 2000;16(5):309-312. (Retrospective study; 134 infants)
  38. Al-Qudah AA. Value of brain CT scan in children with febrile convulsions. J Neurol Sci. 1995;128(1):107-110. (Retrospective case series; 38 pediatric patients)
  39. Warden CR, Brownstein DR, Del Beccaro MA. Predictors of abnormal findings of computed tomography of the head in pediatric patients presenting with seizures. Ann Emerg Med. 1997; 29(4):518-523. (Retrospective case series; 203 pediatric patients)
  40. Garvey MA, Gaillard WD, Rusin JA, et al. Emergency brain computed tomography in children with seizures: who is most likely to benefit? J Pediatr. 1998;133(5):664-669. (Retrospective analysis; 99 pediatric patients)
  41. Hesdorffer DC, Chan S, Tian H, et al. Are MRI-detected brain abnormalities associated with febrile seizure type? Epilepsia. 2008;49(5):765-771. (Prospective cohort study; 159 pediatric patients)
  42. Consensus Development Panel. Consensus statement: febrile seizures: long-term management of children with fever-associated seizures. Pediatrics. 1980;66(6):1099-1112. (Practice guideline)
  43. Sofijanov N, Emoto S, Kuturec M, et al. Febrile seizures: clinical characteristics and initial EEG. Epilepsia. 1992;33(1):52-57. (Prospective study; 676 pediatric patients)
  44. Kuturec M, Emoto SE, Sofijanov N, et al. Febrile seizures: is the EEG a useful predictor of recurrences? Clin Pediatr. 1997;36(1):31-36. (Retrospective study; 269 pediatric patients)
  45. Stores G. When does an EEG contribute to the management of febrile seizures? Arch Dis Child. 1991;66(4):554-557. (Review)
  46. Wo SB, Lee JH, Lee YJ, et al. Risk for developing epilepsy and epileptiform discharges on EEG in patients with febrile seizures. Brain Dev. 2013;35(4):307-311. (Retrospective study; 123 pediatric patients)
  47. Kanemura H, Mizorogi S, Aoyagi K, et al. EEG characteristics predict subsequent epilepsy in children with febrile seizure. Brain Dev. 2012;34(4):302-307. (Retrospective study; 119 pediatric patients)
  48. Berg AT, Shinnar S. Complex febrile seizures. Epilepsia. 1996;37(2):126-133. (Prospective cohort study; 428 pediatric patients)
  49. Sales JW, Bulloch B, Hostetler MA. Practice variability in the management of complex febrile seizures by pediatric emergency physicians and follows. CJEM. 2011;13(3):145-149. (Survey; 353 physicians)
  50. Kimia A, Ben-Joseph EP, Rudlow T, et al. Yield of lumbar puncture among children presenting with their first complex febrile seizure. Pediatrics. 2010;126(1):62-69. (Retrospective cohort study; 526 pediatric patients)
  51. 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):494-447. (Retrospective review; 366 pediatric patients)
  52. Boyle DA, Sturm JL. Clinical factors associated with invasive testing and imaging and patients with complex febrile seizures. Pediatr Emerg Care. 2013;29(4):430-434. (Retrospective cohort; 199 pediatric patients)
  53. Hardasmalani MD, Saber M. Yield of diagnostic studies and children presenting with complex febrile seizures. Pediatr Emerg Care. 2012;28(8):789-791. (Retrospective chart review; 71 pediatric patients)
  54. Fletcher EM, Sharieff G. Necessity of lumbar puncture in patients presenting with new onset complex febrile seizures. West J Emerg Med. 2013;14(3):206-211. (Retrospective cohort study; 193 pediatric patients)
  55. Najaf-Zadeh A, Dubos F, Hue V, et al. Risk of bacterial meningitis in young children with a first seizure in the context of fever: a systematic review and meta-analysis. PLOS One. 2013;8(1):e55270-e55277. (Meta-analysis and systemic review)
  56. Kimia AA, Ben-Joseph EP, Prabhu S, et al. Yield of emergent neuroimaging among children presenting with a first complex febrile seizure. Pediatr Emerg Care. 2012;28(4):316-321. (Retrospective cohort study; 526 pediatric patients)
  57. Teng D, Dayan P, Tyler S, et al. Risk of intracranial pathologic conditions requiring emergency intervention after first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-308. (Retrospective study; 71 pediatric patients)
  58. McAbee GN, Barasch ES, Kurfist LA. Results of the computed tomography in neurologically normal children after initial onset of seizures. Pediatr Neurol. 1989;5(2):102-106. (Combined retrospective and prospective study; 101 pediatric patients)
  59. Maytal J, Steele R, Eviatar L, Novak G. The value of early postictal EEG in children with complex febrile seizures. Epilepsia. 2000;41(2):219-221. (Retrospective chart review; 33 pediatric patients)
  60. Shah PB, James S, Elayaraja S. EEG for children with complex febrile seizures. Cochrane Database Syst Rev. 2014;1:CD009196. (Systemic review)
  61. Wiebe S, Tellez-Zenteno JF, Shapiro M. An evidence-based approach to the first seizure. Epilepsia. 2008; 49 Suppl:50-57. (Literature review and proposed guideline)
  62. Wilden JA, Cohen-Gadol AA. Evaluation of first nonfebrile seizures. Am Fam Physician. 2012;86(4):334-340. (Literature review and proposed guideline)
  63. Eisner RF, Turnbull TL, Howes DS, et al. Efficacy of a "standard” seizure workup in the emergency department. Ann Emerg Med. 1986;15(1):69-75. (Prospective study; 163 children and adults)
  64. Turnbull TL, Vanden Hoek TL, Howes DS, et al. Utility of laboratory studies in the emergency department patient with a new onset seizure. Ann Emerg Med. 1990;19(4):373-377. (Prospective study; 16 children and 120 adults)
  65. Valencia I, Sklar E, Blanco F, et al. The role of creatine serum laboratory tests in children presenting to the emergency department with unprovoked seizures. Clin Pediatr (Phila). 2003;42(6):511-517. (Prospective observational study; 107 pediatric patients)
  66. Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63(4):437-447. (Clinical policy)
  67. Gaillard WD, Chiron C, Cross JH, et al. Guidelines for imaging infants and children with recent-onset epilepsy. Epilepsia. 2009;50(9):2147-2153. (Guideline)
  68. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: neuroimaging in the emergency patient presenting with seizures (an evidence–based review): report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology. 2007;69(18):1772-1780. (Literature review and guidelines)
  69. Shinnar S, O'Dell C, Mitnick R, et al. Neuroimaging abnormalities in children with an apparent first unprovoked seizure. Epilepsy Res. 2001;43(3):261-269. (Prospective observational study; 411 pediatric patients)
  70. Stroink H, Brouwer OF, Arts WF, et al. The first unprovoked, untreated seizure in childhood: a hospital-based study of the accuracy of the diagnosis, rate of recurrence, and long-term outcome after recurrence. Dutch study of epilepsy in childhood. J Neurol Neurosurg Psychiatry. 1998;64(5):595-600. (Prospective study; 156 pediatric patients)
  71. Hsieh DT, Chang T, Tsuchida N, et al. New-onset afebrile seizures in infants: role of neuroimaging. Neurology. 2010;74(2):150-156. (Prospective observational study; 317 patients aged 1-24 months)
  72. Camfield PR, Camfield CS, Dooley JM, et al. Epilepsy after a first unprovoked afebrile seizure in childhood. Neurology. 1985;35(11):1657-1660. (Prospective study; 168 pediatric patients)
  73. Shinnar S, Berg AT, Moshe SL, et al. The risk of seizure recurrence after a first unprovoked afebrile seizure in childhood: an extended follow-up. Pediatrics. 1996;98(2 Pt 1):216- 225. (Prospective study; 407 pediatric patients)
  74. Doescher JS, deGrauw TJ, Musick BS, et al. Magnetic resonance imaging and electroencephalographic findings and the cohort of normal children with newly diagnosed seizures. J Child Neurol. 2006;21(6):491-495. (Prospective study; 181 pediatric patients)
  75. Riviello JJ Jr, Ashwal S, Hirtz D, et al. Practice parameter: diagnostic assessment of the child with status epilepticus (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550. (Practice guideline)
  76. Chin R, Neville B, Peckham C, et al. Incidence, cause, and short-term outcome of convulsive status epilepticus in childhood: prospective population based study. Lancet. 2006;368 (9531):222-229. (Prospective study; 226 patients)
  77. * Singh RK, Stephens SM, Berl M, et al. Prospective study of new onset seizures presenting as status epilepticus in childhood. Neurology. 2010;74(8):636-642. (Prospective study; 144 pediatric patients)
  78. Bassan H, Barzilay M, Shinnar S, et al. Prolonged febrile seizures, clinical characteristics, and acute management. Epilepsia. 2013;56(6):1092-1098. (Prospective study; 60 pediatric patients)
  79. Dunn DW. Status epilepticus in children: etiology, clinical features, and outcome. J Child Neurol. 1988;3(3):167-173. (Prospective study; 97 pediatric patients)
  80. Scott RC, Kirkham FJ. Clinical update: childhood convulsive status epilepticus. Lancet. 2007;370(9589):724-726. (Review)
  81. Nordli DR Jr, Moshé SL, Shinnar S, et al. Acute EEG findings in children with febrile status epilepticus: results of the FEBSTAT study. Neurology. 2012;79(22):2180-2186. (Prospective study; 199 pediatric patients)
  82. Fernandez IS, Loddenkemper T, Datta A, et al. Electroencephalography in the pediatric emergency department: when is at most useful? J Child Neurol. 2014;29(4):475-482. (Retrospective review; 68 pediatric patients)
  83. Treatment of convulsive status epilepticus. Recommendations of the Epilepsy Foundation of America's Working Group on Status Epilepticus. JAMA. 1993;270(7):854-859. (Expert recommendations)
  84. Appleton R, Choonara I, Martland T, et al. The treatment of convulsive status epilepticus in children. The Status Epilepticus Working Party, Members of the Status Epilepticus Working Party. Arch Dis Child. 2000;83(5):415-419. (Guideline)
  85. Abend NS, Dlugos DJ. Treatment of refractory status epilepticus: literature review and a proposed protocol. Pediatr Neurol. 2008;38(6):377-390. (Literature review and proposed guideline)
  86. Lewena S, Pennington V, Acworth J, et al. Emergency management of pediatric convulsive status epilepticus: a multicenter study of 542 patients. Pediatr Emerg Care. 2009;25(2):83- 97. (Retrospective multicenter; 542 episodes of status epilepticus)
  87. Conway JM, Leppik IE, Birnbaum AK. Antiepileptic drug therapy in children. In: Swaiman KF, Ashwal S, Ferriero DM, et al, eds. Swaiman's Pediatric Neurology. 5th ed. Philadelphia, PA: Elsevier-Saunders; 2012;811-835. (Textbook)
  88. Thakker A, Shanbag P. A randomized controlled trial of intranasal-midazolam versus intravenous-diazepam for acute childhood seizures. J Neurol. 2013;260(2):470-474. (Randomized controlled trial; 50 children)
  89. McMullan J, Sasson C, Pancioli A, et al. Midazolam versus diazepam for the treatment of status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med. 2010;17 (6):575-582. (Meta-analysis; 6 studies with 774 patients)
  90. McIntyre J, Robertson S, Norris E, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomized controlled trial. Lancet. 2005;366(9481):205-210. (Randomized controlled trial; 219 episodes of pediatric status epilepticus)
  91. Fischer JH, Patel TV, Fischer PA. Fosphenytoin: clinical pharmacokinetics and comparative advantages in the acute treatment of seizures. Clin Pharmacokinet. 2003;42(1):33-58. (Review)
  92. Smith MC, Riskin BJ. The clinical use of barbiturates in neurological disorders. Drugs. 1991;42(3):365-378. (Review)
  93. Brodie MJ, Kwan P. Current position of phenobarbital in epilepsy and its future. Epilepsia. 2012;53(Suppl 8):40-46. (Review)
  94. Perucca E. Pharmacological and therapeutic properties of valproate: a summary after 35 years of clinical experience. CNS Drugs. 2002;16(10):695-714. (Review)
  95. Abend NS, Monk HM, Licht DJ, et al. Intravenous levetiracetam in critically ill children with status epilepticus or acute repetitive seizures. Pediatr Crit Care Med. 2009;10 (4):505-510. (Retrospective review; 10 pediatric patients)
  96. Yorns WR Jr, Khurana DS, Carvalho KS, et al. Efficacy of lacosamide as adjunctive therapy in children with refractory epilepsy. J Child Neurol. 2014; 29(1):23-27. (Retrospective review; 40 patients)
  97. Rastogi RG, Ng YT. Lacosamide in refractory mixed pediatric epilepsy: a prospective add-on study. J Child Neurol. 2012; 27(4):492-495. (Prospective review; 16 pediatric patients)
  98. Trevathan E, Kerls SP, Hammer AE, et al. Lamotrigine adjunctive therapy among children and adolescents with primary generalized tonic-clonic seizures. Pediatrics. 2006;118(2):e371 -e378. (Randomized blinded prospective trial; 45 pediatric patients)
  99. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3-23. (Practice guideline)
  100. Capovilla G, Beccaria F, Beghi E, et al. Treatment of convulsive status epilepticus in childhood: recommendations of the Italian League Against Epilepsy. Epilepsia. 2013;54(Suppl 7):23-34. (Guidelines)
  101. Riviello JJ, Claassen J, Neurocritical Care Society Status Epilepticus Guideline Writing Committee, et al. Treatment of status epilepticus: an international survey of experts. Neurocrit Care. 2013;18(2):193-200. (Survey; 60 participants)
  102. Sanchez-Fernandez I, Abend NS, Agadi S, et al. Gaps and opportunities in refractory status epilepticus research in children: a multicenter approach by the Pediatric Status Epilepticus Research Group (pSERG). Seizure. 2014;23(2):87-97. (Review)
  103. Minicucci F, Muscas G, Perucca E et al. Treatment of status epilepticus in adults: guidelines of the Italian League Against Epilepsy. Epilepsia. 2006;47(Suppl 5):9-15. (Practice guideline)
  104. Langer JE, Fountain NB. A retrospective observational study of current treatment for generalized convulsive status epilepticus. Epilepsy Behav. 2014;37:95-99. (Retrospective study; 177 episodes of status epilepticus in adults and children)
  105. Cook AM, Castle A, Green A, et al. Practice variations in the management of status epilepticus. Neurocrit Care. 2012;17(1):24-30. (Retrospective multicenter study; 150 patients)
  106. Chamberlain JM, Okada P, Holsti M, et al. Lorazepam vs diazepam for pediatric status epilepticus: a randomized clinical trial. JAMA. 2014;311(6):1652–1660. (Double-blind randomized prospective trial; 273 pediatric patients)
  107. Sreenath TG, Gupta P, Sharma KK, et al. Lorazepam versus diazepam-phenytoin combination in the treatment of convulsive status epilepticus in children: a randomized controlled trial. Eur J Paediatr Neurol. 2010;14(2):162-168. (Randomized prospective trial; 178 pediatric patients)
  108. Appleton R, Sweeney A, Choonara I, et al. Lorazepam versus diazepam in the acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol. 1995;37(8):682-688. (Randomized prospective trial; 102 patients)
  109. * Agarwal P, Kumar N, Chandra R, et al. Randomized study of intravenous valproate and phenytoin in status epilepticus. Seizure. 2007;16(6):527-532. (Randomized prospective trial; 100 patients)
  110. Brevoord JC, Joosten KF, Arts WF, et al. Status epilepticus: clinical analysis of a treatment protocol based on midazolam and phenytoin. J Child Neurol. 2005;20(6):476-481. (Retrospective trial; 122 patients)
  111. Alvarez V, Januel JM, Burnand B, et al. Second-line status epilepticus treatment: comparison of phenytoin, valproate, and levetiracetam. Epilepsia. 2011;52(7):1292-1296. (Prospective trial; 279 adult patients)
  112. Berkowitz R, Koyfman A. What is the best first-line agent for benzodiazepine-resistant convulsive status epilepticus? Ann Emerg Med. 2014;64(6):656-657. (Expert commentary)
  113. Malamiri RA, Ghaempanah M, Khosroshahi N, et al. Efficacy and safety of intravenous sodium valproate versus phenobarbital in controlling convulsive status epilepticus and acute prolonged convulsive seizures in children: a randomised trial. Eur J Paediatr Neurol. 2012;16(5):536-541. (Randomized prospective trial; 60 patients)
  114. Crawford TO, Mitchell WG, Fishman LS, et al. Very-high-dose phenobarbital for refractory status epilepticus in children. Neurology. 1988;38(7):1035-1040. (Retrospective study; 50 pediatric patients)
  115. Mehta V, Singhi P, Singhi S. Intravenous sodium valproate versus diazepam infusion for the control of refractory status epilepticus in children: a randomized controlled trial. J Child Neurol. 2007;22(10):1191-1197. (Randomized prospective trial; 40 pediatric patients)
  116. Glass HC, Pham TN, Danielsen B, et al. Antenatal and intrapartum risk factors for seizures in term newborns: a population-based study, California 1998-2002. J Pediatr. 2009;154 (1):24-28. (Population-based study)
  117. Lanska MJ, Lanska DJ, Baumann RJ, et al. A population-based study of neonatal seizures in Fayette County, Kentucky. Neurology. 1995;45(4):724-732. (Population-based study)
  118. Shellhaas RA, Chang T, Tsuchida T, et al. The American Clinical Neurophysiology Society's guideline on continuous electroencephalography monitoring in neonates. J Clin Neurophysiol. 2011;28(6):611-617. (Guideline)
  119. Glass HC. Neonatal seizures: advances in mechanisms and management. Clin Perinatol. 2014;41(1):177-190. (Review)
  120. Booth D, Evans DJ. Anticonvulsants for neonates with seizures. Cochrane Database Syst Rev. 2004;3:CD004218. (Systematic review)
  121. Slaughter LA, Patel AD, Slaughter JL. Pharmacological treatment of neonatal seizures: a systematic review. J Child Neurol. 2013;28(3):351-364. (Systematic review)
  122. Ramantani G, Ikonomidou C, Walter B, et al. Levetiracetam: safety and efficacy in neonatal seizures. Eur J Paediatr Neurol. 2011;15(1):1-7. (Prospective open-label study; 38 newborns)
  123. Bui TT, Delgado CA, Simon HK. Infant seizures not so infantile: first-time seizures in children under 6 months of age presenting to the ED. Am J Emerg Med. 2002;20(6):518-520. (Retrospective review; 31 infants)
  124. Wills B, Erickson T. Chemically induced seizures. Clin Lab Med. 2006;26(1):185-209. (Review)
  125. Hoffman RJ, Grinshpun A, Paulose DT, Hahn I. Pediatric toxicology update. Emergency Medicine Practice. 2007;9(4):1- 28. (Evidence-based review)
  126. Levine M, Ruha AM. Overdose of atypical antipsychotics: clinical presentation, mechanisms of toxicity, and management. CNS Drugs. 2012;26(7):601-611. (Review)
  127. Finkelstein Y, Hutson JR, Freedman SB, et al. Drug-induced seizures in children and adolescents presenting for emergency care: current and emerging trends. Clin Toxicol. 2013;51 (8):761-6. (Prospective observational study; 142 pediatric patients)
  128. Minns AB, Ghafouri N, Clark RF. Isoniazid-induced status epilepticus in a pediatric patient after inadequate pyridoxine therapy. Pediatr Emer Care. 2010;26(5):380-381. (Case report; 1 pediatric patient)
  129. Morrow LE, Wear RE, Schuller D, et al. Acute isoniazid toxicity and the need for adequate pyridoxine supplies. Pharmacotherapy. 2006;26(10):1529-1532. (Case report; 1 adult patient)
  130. Santucci KA, Shah BR, Linakis JG. Acute isoniazid exposures and antidote availability. Pediatr Emerg Care. 1999;15(2):99- 101. (Survey; 105 hospitals)
  131. Gospe SM, Bell RMS. Hospital pharmacy and emergency department availability of parenteral pyridoxine. Pediatr Emerg Care. 2005;1(9):586-588. (Survey; 149 hospitals)
  132. Shannon M, McElroy E, Liebelt EL. Toxic seizures in children: case scenarios and treatment strategies. Pediatr Emerg Care. 2013;19(3):206-210. (Review)
  133. Reichert C, Reichert P, Monnet-Tschudi F, et al. Seizures after single-agent overdose with pharmaceutical drugs: analysis of cases reported to a poison center. Clin Toxicol. 2014;52(6):629-634. (Retrospective study; 313 adult and pediatric patients)
  134. Thundiyil JG, Kearney TE, Olson KR. Evolving epidemiology of drug-induced seizures reported to a poison control center system. J Med Toxicol. 2007;3(1):15-19. (Retrospective study; 386 adult and pediatric patients)
  135. Spiller HA, Schaeffer SE. Multiple seizures after bupropion overdose in a small child. Pediatr Emerg Care. 2008;24(7):474- 475. (Case report; 1 pediatric patient)
  136. Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort study; 42,412 children)
  137. Haydel MJ, Preston CA, Mills TJ, et al. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000;343(2):100-105. (Prospective two-phase study; 520 adult and pediatric patients for derivation, 909 adult and pediatric patients for validation)
  138. Head injury: triage, assessment, investigation and early management of head injury in children, young people and adults. London (UK): National Institute for Health and Care Excellence; 2014. Available at: http://www.nice.org.uk/guidance/CG176. Accessed August 21, 2014. (Guideline)
  139. Mandal K, West CH. The management of immediate post-traumatic seizures in children following minor head injury – time for a multicentre study? Child's Nerv Syst. 2001;17(11):670- 673. (Retrospective chart review; 13 pediatric patients)
  140. Holmes JF, Palchak MJ, Conklin MJ, Kuppermann N. Do children require hospitalization after immediate posttraumatic seizures? Ann Emerg Med. 2004;43(6):706-710. (Prospective observational cohort study; 63 pediatric patients)
  141. Kim JS, Lee JH, Ryu HW, et al. Effectiveness of intravenous levetiracetam as an adjunctive treatment in pediatric refractory status epilepticus. Pediatr Emer Care. 2014;30(8):525- 528. (Retrospective review; 14 pediatric patients)
  142. Reiter PD, Huff AD, Knupp KG, Valuck RJ. Intravenous levetiracetam in the management of acute seizures in children. Pediatr Neurol. 2010;43(2):117-121. (Retrospective review; 73 pediatric patients)
  143. McTague A, Kneen R, Kumar R, et al. Intravenous levetiracetam in acute repetitive seizures and status epilepticus in children: experience from a children's hospital. Seizure. 2012;21(7):529-34. (Retrospective review; 51 pediatric patients)
  144. Kirmani BF, Crisp ED, Kayani S, et al. Role of intravenous levetiracetam in acute seizure management of children. Pediatr Neurol. 2009;41(1):37-39. (Retrospective chart review; 32 pediatric patients)
  145. Gallentine WB, Hunnicutt AS, Husain AM. Levetiracetam in children with refractory status epilepticus. Epilepsy Behav. 2009;14(1):215-218. (Retrospective review; 11 pediatric patients)
  146. Zelano J, Kumlien E. Levetiracetam as alternative stage two antiepileptic drug in status epilepticus: a systematic review. Seizure. 2012;21(4):233-236. (Systematic review; 10 studies with 334 adult patients)
  147. Jeong JH, Lee JH, Kim K, et al. Rate of and risk factors for early recurrence in patients with febrile seizures. Pediatr Emerg Care. 2014;30(8):540-545. (Retrospective chart review; 228 pediatric patients)
  148. Landau YE, Waisman Y, Shuper A. Management of children with nonfebrile seizures in the emergency department. Eur J Paediatr Neurol. 2010;14(5):439-444. (Retrospective chart review; 85 pediatric patients)
  149. American Academy of Neurology position statement on physician reporting of medical conditions that may affect driving competence. September 2006. Available at: https://www.aan.com/uploadedFiles/Website_Library_Assets/Documents/6.Public_Policy/1.Stay_Informed/2.Position_Statements/3.PDFs_of_all_Position_Statements/mandatory.pdf. Accessed September 12, 2014. (Position statement)
  150. Krauss GL, Ampaw L, Krumholz A. Individual state driving restrictions for people with epilepsy in the US. Neurology. 2001;57(10):1780-1785. (Survey of motor vehicle administration bureaus)
  151. Classen S, Crizzle AM, Winter SM, et al. Evidence-based review on epilepsy and driving. Epilepsy Behav. 2012;23(2):103- 112. (Evidence-based review)
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Authors

Genevieve Santillanes, MD, FAAP, FACEP; Quyen Luc, MD

Publication Date

March 2, 2015

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