This is the second article in our series on Paediatric epilepsy, from Dr Amit Bali, Dr Frances Morrison (Paediatric Consultants) and Dr Leena Mewasingh (Paediatric Neurologist).
This article is aimed at paediatric and emergency medicine trainees working in Paediatric Emergency medicine. For part one of the series, click here.
Why do I need to know about this?
It’s a common reason for Emergency Department (ED) attendance, that’s why! Epilepsy is one of the top 10 causes of paediatric admissions, albeit with a big variation across the country (whilst the average rate is 71.3 per 100000 admissions, this is higher in deprived areas and in children under 5 years of age).
Often, young patients with epilepsies are seen by paediatricians with a special interest in childhood epilepsies, or by neurologists at a tertiary level. This means that trainees seeing them in the ED understandably may not always be that familiar with, or confident in managing, the acute attendances.
Which patients does this guide cover?
This article concentrates on children presenting to the ED with what are judged to be epileptic seizures, as opposed to conditions that may mimic seizures (i.e. paroxysmal events). How to distinguish between seizures and other events is covered in the first article of this series. Another great way of learning more is to attend a Paediatric Epilepsy Training (PET1) course – highly recommended for all senior trainees in paediatrics. The BPNA website also has more information and videos.
There are several reasons that a child might present in the ED after/during a seizure:
- “Provoked” seizures (that is, seizures with an underlying cause, such as fever, acute infections, or metabolic/electrolyte disturbance)
- A first unprovoked seizure (often called “first fit”)
- Breakthrough seizures, in those with a pre-existing diagnosis of epilepsy
They will either be
- in status epilepticus, or
- with an epileptic seizure(s) that has already terminated pre-hospital (with or without having had ‘rescue’ medication, typically a benzodiazepine like buccal midazolam).
Coming to the ED in Status Epilepticus
Convulsive Status Epilepticus is defined as:
- a generalised convulsion lasting >30 minutes, or
- repeated tonic-clonic convulsions happening over 30 minutes without recovery of consciousness in between.
Guidelines for treating Status all refer to seizures lasting more than 5 minutes. The APLS protocol itself will be familiar to most of you reading this, and so this section will not talk through what to do – you can find that algorithm here. Instead, we will go through the principles behind how to do it, and why we do what we do.
1. Don’t panic!
Since managing status epilepticus is oh-so-protocolised, there is usually chance to actually think between each step, so use the time to consider underlying causes.
2. Get the right details from handover
This information can either be from the paramedics or the parents. Things to establish quickly are:
- How long the seizure has been going on (including if it stopped and started again before full recovery)
- What drugs have been given so far, including doses, routes and times
- If known to have epilepsy:
- Do they have an Individualised Emergency Care Plan that gives reason NOT to use the APLS algorithm? If it exists, such a plan may differ from the APLS protocol in what drugs to give, what not to give, and when to give. A great example is the RCPCH Epilepsy Passport
- what AEDs (anti-epileptic drugs) do they usually take?
3. What is correctable/treatable?
In kids presenting in status, think about the following (not exhaustive) list of possible causes:
- Febrile seizure/febrile status (often is made retrospectively)
- Acute infection, e.g. meningoencephalitis
- Metabolic/electrolyte disturbance
- Trauma (including non-accidental injury)
4. Keep thinking ahead
The APLS algorithm gives you a lovely 10 minutes between each intervention hoping the seizure will stop. Not only is this thinking time, it’s planning time!
By prepping the team for the next step or two (e.g. prescribe and prepare drugs, call the anaesthetic team), the running of a status epilepticus call can (and should!) actually be relatively calm. (NB: with second or further doses of benzodiazepines, the risk of respiratory depression increases, so have a low threshold for contacting senior and/or anaesthetic support)
Coming to the ED AFTER a suspected seizure
Children sometimes come to the ED following an episode that is assumed to be a seizure by the time they get triaged, but may or may not actually be an epileptic event. Here’s how to assess and manage their care.
Guess what… it’s all about the history!
As we covered in the first article in this series, the best way to tell the difference between types of paroxysmal events is a proper chronological account of the whole episode, with information from the child themselves, their parent/gran/carer/dog/other eyewitness, and if they have video evidence, even better. Ask about possible triggers for this episode, thinking about the causes of provoked seizures (e.g. are they brewing an infection, was the episode related to a fever, etc). Family history and developmental history is really important in any child presenting with a suspected seizure, as is history/family history associated with provoked seizures (e.g. arrhythmias)
If they already have a diagnosis of epilepsy:
- Did this episode have the same “semiology” (great word! Meaning did it look, feel and act the same as previous seizures?)
- Is this ‘breakthrough’ seizure a one off, or has there been a recent trend of seizures increasing in frequency/duration?
- Are they taking their AEDs? And are they taking the proper dose? Check timings and doses given – beware different concentrations of liquid syrups (tip, ask to see the syringe used if taking liquid formulation)
- When was the last change in dosage? Have they gained weight since the last dose change, i.e. ‘outgrown’ their dose?
Obviously you then need to do a thorough neurological examination.
These acute investigations are essentially to hunt for the causes of provoked seizures:
- Checking glucose, electrolytes, calcium and magnesium after a suspected seizure (NB: a simple febrile seizure doesn’t usually need this level of investigation if there is an obvious source for the fever).
- A 12-lead ECG, to look for long QTc and any arrhythmias. Remember that an ECG can often be normal even if a cardiac cause is present so, if you have a high suspicion of cardiac misbehaviour then you should strongly consider talking/referring to a paediatric cardiologist – especially if there is a family history of early/sudden deaths.
- Other relevant investigations depend on your assessment : e.g. if you suspect acute illness, think about septic screen, if there is decreased level of consciousness, see RCPCH “Management of children and young people with an acute decrease in conscious level” guideline.
Children with signs/symptoms of a precipitating cause for their seizure (i.e. a provoked seizure) should have the underlying cause treated accordingly. Those who have been judged to have had an unprovoked epileptic seizure can be managed as follows:
Who can be safely discharged?
If the young person has fully recovered from the seizure, and no correctable/acutely treatable cause has been identified (which is usually the case), then they can be safely discharged with some follow up in place.
For those presenting with their first epileptic seizure
Follow-up in your local Epilepsy clinic should be arranged (“First Fit” clinic if this is available). This assessment, with a paediatrician with “expertise in epilepsy”, should take place within 2 weeks, as per NICE guidance. Safety advice should be given before discharge from the ED. This is a good video to show parents:
For those with a known diagnosis of epilepsy:
The regular epilepsy team (e.g. the epilepsy specialist nurse) should be told about the attendance, so that:
- Planned review can be brought forward if needed
- Any necessary investigations can be organised
- Any adjustments in therapy can be made quickly
If there are any particular triggers you have uncovered (issues with compliance etc.), then let the epilepsy team so that either they can advise changes for you to make now, or arrange to contact the young person/family themselves.
Who needs admission?
Coming to the ED with a seizure doesn’t necessarily earn an automatic admission, but think about the seizure in context of the severity, frequency and impact. For example, if there is an escalating trend of seizures, the family may need extra training to manage safely.
Admission is generally considered with:
- New-onset seizures that are frequent, or longer lasting
- Known seizures that have changed (e.g. new seizure types, increasing length of seizure)
- Recovery from seizure not complete (i.e. need for further observation). In this scenario, keep in mind alternative diagnoses (e.g. meningoencephalitis).
If it is not clear which category your young patient falls into, then discuss with a senior, and ideally involve a consultant with expertise in epilepsy.
- Status epilepticus: don’t panic! Manage as per APLS, gather information that will help direct your management plan.
- Presenting after a first paroxysmal episode? Take a thorough history thinking about whether this was a seizure or not. Rule out causes of provoked seizures.
- In a child with known epilepsy, make sure this is their usual seizure type, and also think about why a breakthrough seizure might have happened.
- Decide if the child needs admission, or can be safely discharged with follow up? (most fall into the second category).
- Communicate with any epilepsy team members involved in their care – if needed, contact for advice there and then, otherwise you must tell them about the attendance.
- Last but not least: if in doubt, uncertain what to do, or unsure if this was an epileptic seizure, get advice from someone more senior/experienced.
- Never feel pressured to make a diagnosis or a treatment plan if you are not sure – help is always at hand!
References and further information:
- Admissions of inequality: emergency hospital use for children and young people. 2017 Briefing, Nuffield Trust.
- NICE (2004) The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care
- Advanced Paediatric Life Support: A Practical Approach to Emergencies, 2016
- PET1 training