Grunting may be caused by the convulsion and not be a sign of respiratory distress. Significant hypertension (>97th centile for age) indicates a possible aetiology for the convulsion. AVPU score cannot be measured meaningfully. Pupillary size and reaction should be noted however, very small pupils suggest opiate poisoning, large pupils amphetamines, atropine, tricyclic antidepressants and others. Posturing may suggest raised intracranial pressure, which can sometimes be mistaken for a seizure. Consider also drug induced dystonia or psychogenic pseudoseizure. Look for neck stiffness and a full fontanelle, suggesting meningitis. A fever is suggestive of an infectious cause (but its absence does not exclude one) or poisoning with ecstasy, cocaine or salicylates. Hypothermia suggests alcohol or barbiturates.
Even if the airway is open the orophaynx may need secretion clearance by gentle suction. All convulsing children should receive high flow oxygen through a face mask with a reservoir. Take blood for glucose stick and laboratory test. Give 5 ml/kg 10% dextrose to any hypoglycaemic patient. If possible, take 10 ml clotted blood before giving dextrose for later investigation of the hypoglycaemic state. Give bolus of crystalloid if signs of shock, give antibiotic such as cefotaxime if suspected meningitis.
History of febrile illness, recent trauma, epilepsy, poison, last meal.
Patients with chronic epilepsy may have individual protocols which are more appropriate. Seizures in neonates are also treated differently.
Rapid sequence induction of anaesthesia is performed with thiopentone and a short acting paralysing agent. Further advice on management should be sought from a a pediatric neurologist. In children under 3 yrs with a history of chronic, active epilepsy, a trial of pyridoxine should be instituted.
Lorazepam is equally or more effective than diazepam and possibly produces less respiratory depression. It has a longer duration of action (12-24 hours cf 1 hour). If not available, diazepam can be substituted (0.25 mg/kg IV). Lorazepam is poorly absorbed rectally, unlike diazepam.
Paraldehyde should not be made up with arachis oil as children with peanut allergy may react to it. Paraldehyde can cause rectal irritation but IM it causes severe pain and sterile abscesses. Avoid in liver disease. It takes 10-15 minutes to act and lasts for 2-4 hours. Do not leave standing in plastic syringe for more than a few minutes.
Phenytoin is made up in 0.9% saline to a maximum concentration of 10 mg/ml. Measure levels 90-120 minutes after completion of infusion. Can cause dysrhythmias and hypotension. Do not use if child is on oral phenytoin unless level is less than 2.5 mcg/ml.
Fosphenytoin can be administered more quickly than phenytoin (7-10 minutes) and is said to cause fewer cardiac side effects. It can be given IM.
General measures - fluid intake should be kept to 50-60% normal requirements, using 0.45% saline and 5% dextrose. Monitor pulse, BP, respiratory rate, oxygen sats, urine output, blood levels of glucose, urea, creatinine, and electrolytes. The role of cerebral function monitoring is still unclear. After cessation of fit, all children require continuous monitoring for vital functions and to observe for further convulsions. Benzodiazepines used to control the fit may cause respiratory depression. The underlying cause must be considered.
Use the biggest cuff that will fit comfortably. A small cuff gives erroneously high readings. If using an electronic device and the result is unexpected, recheck manually. Raised BP in a child who is fitting, in pain or screaming must be rechecked when calm. If the child is very small or uncooperative, using a doppler device may be helpful. Approximate systolic BP may be obtained by palpation.
Only commence after discussion with paediatric nephrologist or cardiologist because of dangers of too rapid reduction. Monitoring of visual acuity and pupils is crucial as lowering the blood pressure may cause infarction of optic nerve heads. Any deterioration must be treated urgently with IV saline.