On Scene Seizure Ceasing (in Kids)
By Hanna K. Heintz, MD; Paul E. Pepe MD, MPH, FAEMS, MCCM; Megan C. Marino, MD, FAAP, FACEP; Joelle Donofrio-Ödmann, DO, FAAP, FACEP, FAEMS; and Benjamin W. Weston, MD, MPH, FAEMS
Seizures in a child can be a frightening experience, not only for parents and other caregivers, but also for medical care providers. Unfortunately, pediatric seizures occur frequently in children, and they can account for 5% to 15% of all 9-1-1 requests for pediatric emergency care in the U.S.1 Therefore, fortified by recent related research advances, recognition and appropriate treatment of children with seizures should now be considered part of a critical skillset for all prehospital care clinicians.
As a basic premise, one should first delineate and approach pediatric seizures according to two broad categories, namely those with febrile seizures and those with non-febrile seizures.
Febrile seizures generally occur in children between six months and five years of age. They are associated with a febrile illness. Such seizures are typically the consequence of enhanced neuronal excitability that resulted from the rapid rise in core temperature that can often occur in younger children.8 While it is appropriate to treat high fevers with antipyretics (acetaminophen and/or ibuprofen), these medications will generally not treat nor even prevent a febrile seizure. It's important to note, the fever associated with the seizure may be the first presenting symptom of illness, and other associated symptoms may develop in subsequent hours to days.
Most febrile seizures can be considered “simple” febrile seizures which involve a singular event characterized by generalized tonic-clonic motor activity (full body shaking associated with loss of consciousness) that typically persists five to 15 minutes. The vast majority of these seizures will self-resolve in less than five minutes and not require medication to stop. However, a certain percentage of children will experience complex febrile seizures, which may only involve focal motor movements (e.g., a single extremity shaking or isolated eye deviation). These complex seizures may persist longer than 15 minutes, and the seizures may recur one or more times within a 24-hour period.
The peak incidence of first-time febrile seizures in children has been 16 months with 90% of these patients experiencing their first febrile seizure by 3 years of age and as many as 50% of these children having a febrile seizure will experience at least one additional febrile seizure during a future illness prior to the age of six.2 Also, while children with a family history of febrile seizures are more likely to experience a febrile seizure,3 in general, simple febrile seizures do not increase a child’s future risk of developing an on-going seizure disorder. In contrast, a child with a neurodevelopmental disorder and/or developmental delay can have an increased risk of epilepsy.4
Non-febrile seizures are far less common but include causes such an underlying epileptic condition, intracranial infection (e.g., meningitis, encephalitis), traumatic brain injury (e.g., intracranial bleeding), but also systemic causes such as electrolyte disturbances (e.g., hyponatremia, hypoglycemia). Of note, children being treated for epilepsy are more likely to have breakthrough seizures during periods of physiologic stress, such as the onset of some acute illness. For example, prehospital clinicians may be called to attend a child with a seizure who is then also found to have a fever. However, this generally is not categorized as a febrile seizure if the child has been previously diagnosed with a seizure disorder.
Prompt recognition of seizures often can be difficult if classic tonic-clonic motor movements are absent. Specifically, prehospital clinicians should try to observe for the more subtle signs of seizure activity in any child, especially altered mental status. These signs may include abnormal vital signs (i.e., tachycardia, oxygen desaturation, abnormal ETCO2), eye deviation, clenched jaw, or any repetitive, non-suppressible movements. Status epilepticus without an obvious motor component may later be demonstrated by electrographic (EEG) evidence of ongoing seizures. If there is a high suspicion for such conditions, paramedics should still consider rapid treatment in the prehospital setting. If tonic-clonic motor activity has ceased but a patient continues to be unresponsive to painful stimuli, the clinician should continue to treat the patient with seizure medications according to local protocols.
Conversely, some post-ictal states in certain childhood seizure syndromes may appear to be an ongoing state of motor abnormalities. Also, post-anoxic posturing may be mistaken as a convulsive seizure5 and these possible conditions should be assessed and considered when gathering histories.
Regardless of etiology, the emergency management of pediatric seizures follows the usual priorities that involve prompt recognition and treatment of those seizures while also managing the patient’s airway, breathing, and circulation. Persistent tonic-clonic seizures, for example, can compromise proper respiratory excursions leading to oxygen desaturation, abnormal CO2 levels and metabolic acidosis. With that said, rapid treatment and control of the convulsions may also help to reverse those abnormalities.
Seizing neurons often act as a kindling that perpetuate seizures. This further emphasizes the need for rapid administration of rescue medications to reduce seizure duration and, in turn, overall morbidity and mortality. Accordingly, as intramuscular (IM) midazolam has been shown to be as effective as the intravenous (IV) route of administration, it can be the preferred route for initial seizure management in children, especially considering the ability to administer it rapidly.9 Even among the more experienced and highly skilled prehospital clinicians, there is often difficulty in quickly establishing an IV or even intraosseous access in a shaking child. Intranasal (IN) administration has often been fostered as another approach to rapid treatment, but some studies have indicated therapeutic onset for benzodiazepines (or even ketamine) may be delayed or less effective using the IN approach, thus favoring IM.5,6 In addition, for many with known seizure disorders, additional doses of midazolam may be required for persistent status epilepticus. Many EMS agencies also carry levetiracetam and ketamine, both of which have been reported to be used to treat benzodiazepine resistant status epilepticus with early promising results.5
Hypoglycemic seizures are uncommon in the (non-infant) pediatric population (typically only 2% of cases). Therefore, rapid benzodiazepine treatment generally should be prioritized over blood glucose screening, Nonetheless, like all cases of altered mental status, glucose should be checked and hypoglycemia treated as soon as feasible, especially if there is a history of diabetes treatment or if seizures continue to persist. In female teenagers, post-partum eclampsia, though rare in this population, should be considered in any differential assessment of seizures as it requires a different treatment approach. Likewise, undisclosed child abuse or unwitnessed head injury should always be considered in the differential as well.
While critical cardiopulmonary complications such as bradycardia and apnea are infrequent, they still may occur in pediatric seizures secondary to the compromised respiratory function with ongoing convulsions. These complications are more likely to occur in the male sex, children of younger ages, those with longer seizure duration, or in those who have a known epilepsy syndrome.7 At the same time, status epilepticus conditions are more frequent with older females. Regardless of the relative risk, EMS professionals should always remain vigilant and be prepared to support airway, breathing, and circulation as indicated. All patients with any concern for seizure should be transported with continuous heart rate and oxygen saturation monitoring to rapidly identify vital sign changes or abnormalities indicating the need for intervention, particularly in terms of those demonstrating subtle signs of recurrent or complex seizures.
In summary, current best practices for prehospital management of seizures should be focused on prompt recognition of overt ongoing convulsions or detection of a more subtle seizure event. In such cases, the earliest administration of rescue medications is a priority.
About the Authors
Hanna K. Heintz, MD, is a pediatric emergency medicine fellow at the Medical College of Wisconsin.
Paul E. Pepe MD, MPH, FAEMS, MCCM, is coordinator of the Metropolitan EMS Medical Directors (aka “Eagles”) Global Alliance, Dallas, Texas.
Megan C. Marino, MD, FAAP, FACEP, is a pediatric emergency medical specialist and former medical director for New Orleans EMS.
Joelle Donofrio-Ödmann, DO, FAAP, FACEP, FAEMS, is a City of San Diego EMS medical director and pediatric emergency medicine physician at Rady Children’s Hospital San Diego.
Benjamin W. Weston, MD, MPH, FAEMS, is associate professor at the Medical College of Wisconsin and chief medical director for Milwaukee County EMS.
Resident Eagle profiles the work of top EMS physicians and medical directors from the Metropolitan EMS Medical Directors Global Alliance (Eagles), who primarily represent the largest U.S. cities and jurisdictions. For information on the Gathering of Eagles conferences, see useagles.org.
References
1. Abramson TM, Rose E, Crow E, Lane CJ, Kearl Y, Loza-Gomez A. Paramedic Identification of Pediatric Seizures: A Prospective Cohort Study. Prehosp Emerg Care. 2021 Sep-Oct;25(5):682-688. doi: 10.1080/10903127.2020.1831667. Epub 2020 Nov 11. PMID: 33026283.
2. Eilbert W, Chan C. Febrile seizures: A review. J Am Coll Emerg Physicians Open. 2022 Aug 23;3(4):e12769. doi: 10.1002/emp2.12769. PMID: 36016968; PMCID: PMC9396974.
3. Tiwari A, Meshram RJ, Kumar Singh R. Febrile Seizures in Children: A Review. Cureus. 2022 Nov 14;14(11):e31509. doi: 10.7759/cureus.31509. PMID: 36540525; PMCID: PMC9754740.
4. Zhang J, Jing Q, Li S, Liu Y, Lin Z, Han X, Xu G, Dai S, Zhang J, Ren C. Risk factors for secondary epilepsy following febrile seizures in children: A meta-analysis. Epilepsy Behav. 2024 Dec;161:110051. doi: 10.1016/j.yebeh.2024.110051. Epub 2024 Sep 21. PMID: 39306980.
5. Scheppke KA, Pepe PE, Garay SA, et al. Effectiveness of Ketamine As a Rescue Drug for Patients Experiencing Benzodiazepine-Resistant Status Epilepticus in the Prehospital Setting. Crit Care Explor 2024 Dec 6;6(12):e1186. doi: 10.1097/CCE.0000000000001186. PMID: 39642307, PMCID: PMC11627481
6. Ramgopal S, Owusu-Ansah S, Crowe RP, Okubo M, Martin-Gill C. Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services. Epilepsia. 2024 May;65(5):1294-1303.Remick K, Redgate C, Ostermayer, D, Kaji AH, Gausche-Hill M. Prehospital Glucose Testing For Children with Seizures : A Proposed Change In Management. Prehosp Emerg Care 2017;21:216–221
7. Singh K, Katz ES, Zarowski M, Loddenkemper T, Llewellyn N, Manganaro S, Gregas M, Pavlova M, Kothare SV. Cardiopulmonary complications during pediatric seizures: a prelude to understanding SUDEP. Epilepsia. 2013
Jun;54(6):1083-91. doi: 10.1111/epi.12153. Epub 2013 Apr 5. PMID: 23731396; PMCID: PMC5304951.
8. Han JY, Han SB. Pathogenetic and etiologic considerations of febrile seizures. Clin Exp Pediatr. 2023 Feb;66(2):46-53. doi: 10.3345/cep.2021.01039. Epub 2023 Jan 13. PMID: 36635899; PMCID: PMC9899550.
9. Shah MI, Macias CG, Dayan PS, et al. An Evidence-Based Guideline For Pediatric Prehospital Seizure Management Using Grade Methodology. Preh Emerg Care 2014;18(Suppl 1):15–24
