Scenario 1

Emily is a fifteen month old girl brought in by ambulance with her mother. Her mother reports she has had a runny nose and cough for two days and was quieter than usual this morning. At 11:00 her mother noticed she felt hot and went to find her some paracetamol.

On return one minute later, she found Emily unresponsive, with her eyes rolled back and jerking confined to the right arm and leg. By the time Emily arrives at the emergency department, she has been having a seizure for 15 minutes. Her temperature is 39.2’C.

She is now having a generalized seizure. There is no known history of seizures or epilepsy.

 

Question 01

What is your initial management of Emily?

Place the following steps in order.

A. Perform Blood Sugar Level (BSL)

B. Obtain IV access

C. Clear the airway, lie on the side, give O2

D. Support respiration if apnoeic

E. Paracetamol
C. D. A. E. B
D. C. A. E. B
A. B. C. D. E
B. C. D. A. E
C. D. B. A. E
Check answer

Explanation

The correct order was - C. D. B. A. E

  • Clear the airway, lie on the side, give oxygen. No objects should be placed into the child's mouth (apart from airway adjuncts such as Guedel airway, although this is often not possible due to clenched teeth.)
  • Support respiration if apnoeic using a bag and mask.
  • Obtain IV access. Give a bolus of 20ml/kg 0.9% saline to any child with signs of shock.
  • Perform Blood Sugar Level (BSL). If hypoglycaemia is present (BSL < 3.5), give IV 10% dextrose 5mL/kg or glucagon 0.5 mg (< 5 yr) im/iv or 1 mg (> 5yr) followed by IV glucose or carbohydrate feed (if conscious).
  • Paracetamol should be given but is not required as immediate first line management in the child who is fitting as it takes up to 40 minutes to have effect.

Question 02

When a child is having a seizure, how long should you wait before giving medication?

Which one of the following is the best answer:
1 minute
2 minutes
5 minutes
10 minutes
15 minutes
Check answer

Explanation

Generalised status epilepticus is defined as a seizure or clusters of seizures lasting for more than 30 minutes without regaining consciousness in between.

The outcome of status epilepticus is mainly determined by its cause. The duration of the seizure is also relevant and the longer a seizure episode, the more difficult it is to terminate.

In general, the majority of seizures (in particular febrile convulsions) are brief and last for less than five minutes.

Seizures lasting longer than five minutes are less likely to stop spontaneously and thus anticonvulsive treatment is usually instituted in any seizure lasting more than five minutes.

Question 03

Assuming the seizure does not stop and Emily has intravenous access, what would be your approach to medication? Choose four of the following medications and place them in the best order:

A) IV phenytoin
B) Thiopentone and intubation
C) IV midazolam first dose
D) IV phenobarbitone
E) IV midazolam second dose
B, E, A, C
C, A, E, B
A, E ,D, B
C, E, A, B
E, A, B, C
Check answer

Explanation

Answer: (in order) C, E, A, B (not D).

In a child with intravenous access who has been fitting for longer than five minutes, the first two doses of medication are benzodiazepines, preferably midazolam, given five minutes apart.

Diazepam is also used but is not as efficacious as midazolam. Lorazepam is not licensed for use in Australia at this time. Any doses given by parents or ambulance officers are considered in these two doses.

This is then followed by phenytoin five minutes later. Phenobarbitone is generally reserved for neonates and would not be used as first line in this child. Phenytoin is given over 20 minutes, but if the child is still fitting after a further ten minutes, appropriate anaesthetic support needs to be obtained and consideration of rapid sequence induction and intubation with Thiopentone given.

NSW Health Guideline: Children and Infants with Seizures

- Acute Management

See the assessment and initial management flowchart on pages 10 and 11.

Question 04

Assuming the seizure does not stop and Emily does NOT have intravenous access, which medication would you use? Which one of the following is the best answer:
IM diazepam
Buccal midazolam
PR diazepam
PR paraldehyde
nil medications until IV access obtained
Check answer

Explanation

Both buccal midazolam and PR diazepam can be used and will have fairly quick onset of action. However, buccal midazolam is generally easier to administer and more socially acceptable than PR diazepam.

It has also been shown to be more effective. Paraldehyde is suggested following two doses of benzodiazepine in those who still do not have intravenous access. Unfortunately, it is not available in all hospitals but is still justified in the literature.

A child without intravenous access who is still fitting after two doses of benzodiazepine will generally have an intraosseus inserted.

Question 05

In this case, which feature indicates the seizure is NOT a simple febrile convulsion?

Which one of the following is the best answer:
Age
Length of seizure
Length and focality of seizure
Lack of family history
Female sex
Check answer

Explanation

A simple febrile convulsion is defined as:

  • occurring in a child between six months and six years
  • in the setting of an acute febrile illness
  • generalised tonic-clonic seizures
  • lasting less than 15 minutes
  • without previous afebrile seizures
  • without significant prior neurological abnormality
  • without CNS infection
  • do not recur within the same febrile illness.

Febrile convulsions occur in three per cent of healthy children, are benign and normally occur in the context of a simple viral infection.

Complex febrile convulsions have one or more of the following:

  • focal features at onset or during the seizure
  • duration of more than 15 minutes
  • recurrence within the same febrile illness
  • incomplete recovery within one hour.

Many neurologists prefer to categorise complex febrile convulsions as 'seizures associated with fever'.

This is because the focal or prolonged nature of the seizure is more likely to be associated with an underlying anatomical cause or epileptic syndrome. As such, there should be hesitancy about considering them in the same category as simple febrile convulsions, especially when counselling parents regarding recurrence and further investigation.
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