by KERRY LEUPOLD, DO
Copyright © 2008 by Leonard Publications, Inc.
All rights reserved. No portion of this article may be reproduced or used in any form without the written consent of Leonard Publications, Inc.
After reading this article the EMT should be able to:
o define a seizure;
o list the types of seizures pediatric patients experience;
o understand the conditions that may mimic a seizure;
o discuss the prevalence of febrile seizures in pediatric patients;
o define status epilepticus;
o describe the EMT management of pediatric seizures;
o list appropriate questions EMTs need to ask parents/caregivers of pediatric seizure patients;
o discuss the importance of reassuring parents/caregivers of pediatric patients who are seizing.
(When you have finished reading this article, you can use this link or one at the end to return to Gold Cross CEU Test #35-49.)
Introduction
"Child Seizing" is a common EMS dispatch. About five percent of all children experience a seizure by the age of three.
No pediatric call may be more puzzling for EMTs. Seizures call for keen observation and investigation: What do we see and how do we manage the condition? Is the infant or child actually having a seizure, or is it a condition that mimics a seizure? And what about the many times EMS arrives only to discover that the child is no longer seizing?
In this article, we will discuss the various types of seizures, their etiologies (or causes), signs and symptoms, and how EMTs should manage a seizing pediatric patient. We will also briefly discuss how to deal with the parents or caregiver. Remember: When a child is ill or injured, there are two patients -- the child and his parent or caregiver. Both deserve immediate attention.
What Is A Seizure?
Brain cells communicate by electrical impulses. When the brain's electrical activity goes awry, the result can be a seizure. A seizure is defined as a transient, involuntary disturbance of cerebral functioning as a result of a sudden discharge of electrical activity in the brain. Seizures cause abnormal, uncontrollable movements or behaviors.
There are all types of seizures, big and small, affecting only part or all of the brain. The seizing child may be "convulsing" with eyes rolling back into his head, arms and legs rigid and jerking, or merely displaying subtle signs of inattention such as staring or eyes fluttering. Parents sometimes discount minor seizure activity as unimportant until it recurs.
It is important to understand that a seizure is not a disease but a symptom. For example, a seizure may result in the patient who has experienced head trauma, or ingested drugs, or has a high fever. Indeed, febrile (or fever) seizures are the most common type of seizures in the pediatric age group.
There are dozens of types of seizures with multiple causes to account for them. Epilepsy, also known as "seizure disorder," is when a person has more than one occurrence of seizures without a fever or any other underlying cause. Epilepsy is fairly common: In the United States, about two and a half million people have epilepsy. It can be inherited or caused by damage to the brain. Often the cause is unknown. Many epileptic syndromes originate in childhood or even in infancy, presenting with seizures.
Although the initial prehospital management is the same for all seizures, ultimately each may require a different level of intervention at the hospital. Remember: All first-time seizure patients must be evaluated in the emergency room. In addition, any patient with a seizure lasting more than ten minutes should immediately be transported in the ambulance with the paramedics on board.
Types of Seizures
Seizures are categorized as either focal or generalized, that is involving part or all of the body.
Partial, or focal seizures, occur in one particular part of the body and cause specific symptoms. (Focal means starting at a focused point or single location.) The problem can be caused by tumor, blood vessel malformation, or a scar following trauma, infection or stroke.
Partial seizures account for 40% of seizures in children and are classified as either simple or complex. These seizures are characterized by repetitive jerking of an extremity, deviation of the eyes to one side, or numbness or tingling in one area of the body. Typically the EMT witnesses the child's arm or leg jerking or twitching continuously. The patient's level of consciousness (LOC) may or may not be impaired depending upon the area of the brain affected. If there is no LOC impairment, the seizure is classified as "simple partial." If there is, the seizure is classified as "complex partial."
A simple partial seizure (SPS) is generally brief, lasting only seconds. The child remains awake and aware but may hear, see, smell, or taste things that aren't real. He may also suddenly feel afraid, angry, happy or sad for no reason. He may become confused or experience jerking or tingling in an arm or leg.
Complex partial seizures (CPS) are associated with an altered level of consciousness. They may be preceded by an aura or simple partial seizure which may not be recognized. The episodes may be very brief and subtle; the pediatric patient may have a short staring episode or pause all activity. In many cases there will be associated "automatisms," which are automatic, uncontrolled movements such as lip smacking, chewing, swallowing, or picking or pulling at clothing, or rubbing an object in a repetitive way. The patient does not remember this activity. CPS may spread and result in a generalized tonic-clonic seizure. These seizures usually last one-to-two minutes.
Generalized seizures involve the entire body and produce a variety of symptoms. This type of seizure is often frightening to witness and especially horrible when it is prolonged.
There are several different types of generalized seizures. Let's first, however, examine their different phases.
Seizures may be preceded by an aura, or an unusual sensation felt by the child minutes or seconds before the attack. An aura may affect the child's sense of smell or sight, sound and even taste. He may feel a "sinking" sensation in his stomach or hear noise or music. Not all seizures are preceded by an aura.
The child then experiences a loss of consciousness and the abnormal muscle, or motor activity begins. In the tonic phase, there is an increased stiffening, or contraction, of the patient's muscles. His legs and arms flex and extend; the muscles of the jaw contract and the mouth remains rigidly closed. He may froth at the mouth or bite his tongue, increasing the possibility of airway complications.
In the clonic phase, the child experiences a rhythmic contraction and relaxation of his muscles. He may turn blue owing to his respiratory muscles (diaphragm and intercostal muscles), being temporarily "frozen." He may urinate uncontrollably as his bladder is squeezed by his abdominal muscles.
Generalized seizures may present as merely tonic or clonic, or even tonic-clonic. Tonic-clonic seizures are what people typically refer to when they use the term "convulsion." There is a sudden loss of consciousness, the eyes roll back into the skull, and the patient foams at the mouth. The body becomes stiff, or tonic. As the seizure progresses, the body becomes clonic with a rhythmic contraction and relaxation of the muscles, or shaking type movements. Then suddenly, the convulsion stops; it generally lasts less than five minutes, although it may seem like hours.
During the subsequent postictal phase, the child awakens, exhausted and confused. He may be not breathing (apneic) and cyanotic. Once respirations resume, there may be copious amounts of oral secretions, or frothing. He may complain of headache and there may be problems neurologically with inability to comprehend or follow commands. The child may resume sleeping for hours.
o A febrile seizure is a tonic-clonic seizure associated with fever, commonly occurring in children less than six years of age. More on this subject later in this article.
o Absence seizures, (pronounced ab-SAHNCE) formerly called petit mal seizures, usually occur in children older than five years of age and are more common in girls. They are brief, lasting seconds, and involve a complete stop of activity and eye flickering. There is no aura and no postictal state, so they may easily go undetected. Most children outgrow this type of seizure in adolescence.
o Myoclonic, or minor motor seizures of childhood, are a group of disorders that involve brief, jerking movements associated with a loss of body tone, causing the patient to fall forward.
o Infantile spasms are seizures in babies that are characterized by brief, symmetric contractions of the neck, trunk and extremities. The movements may be preceded by a cry and often occur when the child is drowsy, or just after waking up. In many cases infantile spasms are associated with mental retardation.
Febrile Seizures
Febrile seizures are very common in pediatrics and occur in two-to- five percent of children by their fifth birthday. About one-third of these patients have at least one recurrence.
Febrile seizures are typically self-limiting, lasting less than 15 minutes. They occur in children of all races and both sexes although some studies demonstrate that boys have a slightly higher number of febrile seizures than girls.
By definition, a febrile seizure is a seizure associated with fever but without any underlying cause or intracranial infection, such as meningitis. Viral illnesses are the most common cause of febrile seizures.
A simple febrile seizure appears as generalized tonic-clonic convulsions associated with fever. A complex febrile seizure is characterized by one or more of the following: Seizure activity that lasts more than 15 minutes; recurs within 24 hours; or is focal. This may indicate a more serious disease process, such as meningitis or encephalitis.
Young children are susceptible to frequent infections and respond with comparably higher temperatures than adults. Any illness that causes a fever can provoke a febrile seizure. In many cases, the seizure may be the child's first sign of illness. (Interesting enough, there is no data to support the theory that a rapid rise in temperature is a cause of febrile seizures.) Commonly associated infections involve the upper respiratory tract, throat infections, ear infections, pneumonia, gastroenteritis and viral illnesses. (All often contracted at the daycare center!)
EMTs should also be aware that not every child who is having a seizure and is whose skin is hot, is having a febrile seizure. Seizure activity -- muscles which are constantly contracting and relaxing thereby producing heat -- can cause the skin to become hot. This phenomenon can mislead EMS providers.
Because febrile seizures are often frightening to parents and caregivers, they need your reassurance. The parents often assume that the child has epilepsy or that there will be permanent brain damage following the event. They need to understand that neither is true but that the child is at an increased risk of having a second febrile seizure some time in the future. Therefore, take time to instruct them in how to care for the child should that happen again. (Photo 1 and Figure 1)
Seizure Look-Alikes
There are many conditions that mimic seizures. The most common one is syncope.
o Syncope occurs as a result of decreased cerebral blood flow, leading to a sudden loss of consciousness and physical collapse. Most cases of syncope are caused by vasovagal stimulation, i.e., pressure on the vagus nerve (the tenth cranial nerve) which causes a decrease in heart rate and leads to hypoperfusion of the cerebral vessels. What can confuse EMTs is that in addition to loss of consciousness, about half of the affected patients experience tonic contractions of the face, trunk, and extremities. Additionally, the eyes may roll upward.
To differentiate syncope from seizures, it is important for EMTs to get a history of events leading up to and following the event. Remember: Syncope is uncommon in children less than ten years of age; there may, however, be nausea and sweating, and a history of prolonged standing, anxiety, pain, or fear. Notably, there is no postictal phase.
o Breath holding spells are another common condition often mistaken for seizures. They generally occur in children between the ages of six months and five years of age and are classified as being either cyanotic or pallid.
Cyanotic breath holding spells are more common and occur after a period of crying associated with an upsetting event, followed by forced expiration and apnea. This results in cyanosis and sudden loss of consciousness, sometimes with jerking movements.
Pallid spells are generally provoked by pain or fear. The child becomes apneic, turns pale, and loses consciousness. There may be tonic movements.
It is easy to see how these conditions may be confused with seizures, but remember the importance of the patient history. The events leading up to the actual "seizure" are important to identify, and in breath holding spells, there is no postictal phase.
o Night terrors may also be confused for seizures. This is a common occurrence in children between the ages of two and six years of age and involves the child suddenly waking from sleep, screaming and frightened. His heart rate and respirations are rapid and his pupils dilated. He is inconsolable and confused and does not remember what happened. The event lasts between ten and 15 minutes and ends as he falls back to sleep.
o Pseudoseizures generally occur in adolescent girls and are psychological in nature. The patient has a familiarity with seizures; either the patient or a family member may truly have a seizure disorder. She then actually "fakes" a seizure. Although this diagnosis can be difficult to make and must only be made after ruling out an organic cause, there are clues that may help in the diagnosis. The patient's pupils react normally to light, there is no incontinence. Although she may thrash around bizarrely, she avoids injuring herself.
Life Threatening Seizures
Seizures are generally not life threatening unless they are prolonged. Any single seizure lasting more than 30 minutes, or recurrent seizures without recovery of consciousness in-between, are termed status epilepticus (SE) and are true neurological emergencies. SE is most common in younger children with forty percent occurring in those less than two years of age. As the seizure continues, the brain tissue receives less oxygen (becomes anoxic) and is damaged. This may result in permanent changes in cerebral function, causing retardation or even death.
Initial Assessment: ABC
The initial goal of the EMT is, of course, to stabilize the patient and prevent him from injuring himself. At the same time, another crew member should get a detailed history of the event from the family or caregivers. (Obviously, if the patient is unstable, he may require immediate attention by both crew members, and these questions will have to be asked while attending to the patient.)
o Initial Assessment: Your first action is to make sure the patient is in a safe position, either on the floor unimpeded by furniture or on the bed, away from its edge. (Photo 2) Correct positioning can be troublesome. While turning him on his side helps drain secretions from the mouth and protects the airway, it may make ventilation difficult. Keeping the patient supine increases possible aspiration and airway problems.
o If the patient is actively seizing, do not attempt to restrain his movement, but clear the scene to prevent injury.
o Stabilize the cervical spine only if there is evidence of trauma. This is rarely the case in seizures. The unnecessary use of cervical collars may interfere with the airway.
o Next, quickly loosen tight clothing or restraints. If the infant or child is febrile, consider removing some of his clothing to cool him down. Do not, however, allow the child to become hypothermic!
o Assess the child's level of consciousness with the AVPU scale. With infants and small children, you may have to ask the parents/ caregivers if the patient is responding normally.
o Assess the ABCs. Remember that patients with impaired consciousness (responds only to verbal or painful stimuli or is unresponsive) could have a compromised airway.
Airway: If the patient has been seizing for more than 15 minutes or there have been consecutive seizures, the patient needs to be treated aggressively with airway management.
o The airway may be obstructed by the tongue. Open the airway with a jaw thrust or chin lift-head tilt maneuver.
o There will likely be excessive oral secretions including saliva and blood especially if the patient has biten his tongue while seizing. Clear the mouth with suction; never put your fingers into the mouth to clear the airway! (Photo 3)
o Remove anything that might have been placed in the mouth. Do not place a blade in the mouth to prevent "swallowing" of the tongue as it has been shown to be potentially harmful.
Breathing: Consider a nasopharyngeal airway but only with patients aged one year and older. Do not use oropharyngeal airways as they can cause a gag reflex that may result in vomiting and possible aspiration.
o If the patient is cyanotic, if the seizure has lasted for ten minutes, or if respirations have not returned to normal once the seizure is over, assist ventilations with a bag valve mask and 100% oxygen. Be sure and use a proper-sized pediatric BVM! (Photo 4) If the patient is postictal, or is actively seizing but has adequate respirations, a nonrebreather mask should be placed over the nose and mouth with oxygen delivery at 15 liters per minute.
Circulation: Check capillary refill, skin, pulse and do a quick sweep for major bleeding. Any condition that interferes with circulation may lead to seizures.
Determine Priority: How long has the patient been seizing? Is this the first time he has ever seized? Does he have a history of seizures? Does he have a fever? The answers to these questions will help determine patient priority.
Most children should be transported to the hospital whether or not the seizure is witnessed by EMS. If the patient is actively seizing, transport to the nearest hospital should be expedited with ALS on board. Remember that status epilepticus is a medical emergency and may result in permanent neurologic disability.
Focused History & Physical Exam: Examine the child fully. Assess mental status to determine if the patient is postictal. Check pupils for size, symmetry, and reactivity. Check the scalp carefully for any swelling or evidence of injury. Examine the skin for a rash. Skin temperature should always be assessed. Obtain a set of vital signs: Pediatric patients who have seized may have elevated heart rates and/or respirations. Check for bowel or bladder incontinence. In a child with an altered mental status, be sure and look for a bracelet or necklace with his medical history.
Remember that febrile seizures are very common in young children, and a documented temperature is critical in establishing this diagnosis. Most important: Even though the patient may appear stable, seizures can recur at any time. Be prepared!
Questions to Ask
In most cases, when 911 is called for "pediatric seizures," the event is over when the EMTs arrive. However, it is the EMT's job to document and report a history of the past event to report to the emergency department.
Take a detailed history, asking eyewitnesses to describe the event as clearly as possible. (Remember that witnessing a seizure often provokes anxiety and that length of time of the event is often overestimated.) It is essential to establish a description of the seizure and how long it lasted.
Ask the following questions:
o What happened just before the event? Were there any symptoms consistent with an aura?
o Has the child ever had a seizure? Was it related to fever, epilepsy, head injury or some other medical condition? Is the child taking medication for a seizure disorder?
o What are the names of the medications?
o Has the child been given his medications as prescribed? In a patient with a known seizure disorder, the cause of the seizure is often subtherapeutic or inadequate drug levels. For this reason, it is important to identify which medications the patient is taking. Several drugs may also cause seizures including some anticonvulsants!
EMTs should also establish whether the parents/ caregivers have already given any medication to the patient for the seizure activity. Many parents are given Valium® suppositories for their child's seizures and are instructed in their use. Side effects of Valium® are respiratory depression and sedation.
o Did the patient recently fall or hit his head? (Are there any signs of physical abuse?) Seizures may be a sign of intracranial injury. Furthermore, a contact seizure, which is a generalized seizure, can occur after head trauma. Conversely, a patient may fall while seizing and sustain head injury.
o When did the seizure begin and how long did it last?
o Does the child have a fever or illness now?
o What did the seizure look like? How did the child's body move during the seizure? Did the arms and legs get stiff, then jerk? Did the arms and legs go limp? Did one or both of the arms and legs move? Did the movement start in one area of the body and move to others? What other parts of the patient's body moved (for example, mouth twitching)? Did the shaking of the arms and legs stop and start again?
o Did the child have any difficulty breathing or stop breathing?
As stated earlier, when EMTs arrive on scene for pediatric seizure dispatches, the event is often over and the patient is postictal. The child may be confused, irritable, or fatigued. She may complain of headache or muscle pain. She may even vomit. It is essential to document these findings, as this evidence is important for the physician in establishing a diagnosis.
Conclusion
EMTs are often called upon to evaluate a seizing pediatric patient. It is important to realize that the "seizure" may be witnessed by non-medical personnel, so a careful history must be sought by EMTs.
Remember that there are many causes of seizures, and that the underlying disorder must be treated at the hospital.
As with any patient, initial assessment with the ABCs is imperative, as seizures may be associated with impaired ventilation and oxygenation.
If the patient is actively seizing upon arrival, transport to the nearest hospital should be expedited, as status epilepticus is a true medical emergency.
Finally, as with any pediatric call, remember to treat the parents/caregivers as well as the patient. Few things are more frightening to witness than a child having a seizure.
Kerry Leupold, DO, is an attending physician in the pediatric emergency room at Robert Wood Johnson University Hospital, New Brunwick.
Return to Gold Cross CEU Test #35-49.