Paediatric Seizures: Febrile Seizures, Status Epilepticus, First-Line Treatment

Paediatric Seizures: Febrile Seizures, Status Epilepticus, First-Line Treatment

A high-density, practical guide for clinicians, nurses, and first responders.

What Is This?

Paediatric seizures are sudden, uncontrolled electrical disturbances in the brain that manifest as convulsions, altered consciousness, or abnormal movements. This guide focuses on febrile seizures (common, benign) and status epilepticus (life-threatening), including first-line treatment to stop seizures quickly and safely.

Why use this today? Seizures are a medical emergency in children. Misdiagnosis or delayed treatment can lead to brain injury, respiratory failure, or death. This guide ensures you recognise, classify, and act within minutes.

Why It Matters

• Febrile seizures affect 2–5% of children under 5, often causing parental panic.
• Status epilepticus (seizure >5 mins or recurrent without recovery) has a mortality rate of 3–5% and risks long-term neurological damage.
• First-line drugs (benzodiazepines) must be given within 5–10 minutes to prevent progression.
• Incorrect dosing (e.g., underdosing midazolam) or wrong route (e.g., oral instead of buccal) wastes critical time.

Core Concepts

1. Febrile Seizures: Simple vs. Complex

Key point: Most febrile seizures are simple and self-limiting. Complex seizures require neurology referral and EEG/MRI.

2. Status Epilepticus (SE): Definition & Phases

• Definition: Seizure lasting >5 mins or ?2 seizures without full recovery between them.
• Phases:
• Early SE (0–5 mins): Seizure starts. First-line treatment (benzodiazepines) must be given here.
• Established SE (5–30 mins): If first-line fails, move to second-line (phenytoin, levetiracetam).
• Refractory SE (>30 mins): Requires ICU admission, anaesthetics (midazolam/propofol), EEG monitoring.

Key point: Time = brain cells. Every minute of untreated SE increases neuronal damage.

3. First-Line Treatment: Benzodiazepines

Key point: - Buccal midazolam is first choice if no IV access. - Lorazepam IV is preferred in hospital (longer action). - Never give oral meds during an active seizure (aspiration risk).

4. ABCDE Approach: Stabilisation

1. Airway: Position in left lateral (recovery position) to prevent aspiration.
2. Breathing: Give oxygen (10–15 L/min via non-rebreather mask).
3. Circulation: Check pulse, BP, capillary refill. IV access if possible.
4. Disability: Assess GCS, pupil reaction, glucose (hypoglycaemia can mimic seizures).
5. Exposure: Check for rash (meningitis), fever, injuries.

Key point: Hypoglycaemia (BM <3 mmol/L) must be corrected (give 2 mL/kg 10% dextrose IV).

How It Works: Step-by-Step Management

1. Febrile Seizure (Simple)

Scenario: A 2-year-old has a 3-minute tonic-clonic seizure with fever (39°C). Parents call ambulance.

Steps:
1. Stay calm. Most febrile seizures stop on their own.
2. Time the seizure. If >5 mins, treat as status epilepticus.
3. Position safely: Left lateral, remove hazards.
4. Check temperature. Give paracetamol (15 mg/kg) or ibuprofen (10 mg/kg) if fever >38.5°C.
5. Reassure parents. Explain low epilepsy risk, no need for EEG/MRI unless complex.
6. Discharge with safety advice: - When to return: Seizure >5 mins, focal signs, or fever + stiff neck (meningitis risk).

2. Status Epilepticus (First-Line Treatment)

Scenario: A 4-year-old is still seizing after 5 minutes. No IV access.

Steps:
1. Call for help (ambulance/rapid response team).
2. Administer buccal midazolam: - Dose: 0.3 mg/kg (max 10 mg). - How: Draw up in syringe, place between cheek and gum, inject slowly.
3. Wait 5 mins. If still seizing, repeat dose once.
4. If no IV access after 2 doses, consider intranasal midazolam (same dose) or IM midazolam.
5. If IV access obtained, give lorazepam 0.1 mg/kg IV (max 4 mg).
6. If seizure persists after 10 mins, move to second-line (phenytoin 20 mg/kg IV over 20 mins).

Key point: Do not delay treatment waiting for IV access. Buccal/IN midazolam works in 3–5 mins.

Hands-On: Drug Calculations & Administration

Prerequisites

• Knowledge: Basic paediatric drug dosing (mg/kg).
• Equipment:
• Midazolam (5 mg/mL or 10 mg/2 mL vial).
• Syringes (1 mL, 2 mL, 5 mL).
• Oxygen mask, suction, glucometer.

Step-by-Step: Buccal Midazolam

Example: 15 kg child.

1. Calculate dose:
2. 0.3 mg/kg × 15 kg = 4.5 mg.
3. Midazolam concentration: 5 mg/mL.

4. Volume = 4.5 mg ÷ 5 mg/mL = 0.9 mL.

5. Draw up 0.9 mL in a 1 mL syringe.

6. Administer:

7. Place child in left lateral position.
8. Insert syringe into buccal cavity (between cheek and gum).
9. Inject slowly (over 10–15 seconds).

10. Hold mouth closed for 10 seconds to prevent spitting.

11. Monitor:

12. Respiratory rate (risk of depression).
13. Seizure cessation (should stop within 5 mins).

Expected outcome: Seizure stops within 3–5 mins. If not, repeat dose once.

Common Pitfalls & Mistakes

1. Underdosing Benzodiazepines

• Mistake: Giving 0.1 mg/kg midazolam (too low) due to fear of respiratory depression.
• Fix: Use 0.2–0.3 mg/kg (max 10 mg). Respiratory depression is rare at correct doses.

2. Wrong Route (Oral Instead of Buccal/IN)

• Mistake: Trying to give oral diazepam during a seizure (aspiration risk).
• Fix: Never give oral meds during active seizures. Use buccal/IN/IV.

3. Delaying Second-Line Treatment

• Mistake: Repeating benzodiazepines >2 times without moving to phenytoin/levetiracetam.
• Fix: If seizure persists after 2 doses of benzodiazepines, escalate to second-line drugs.

4. Ignoring Hypoglycaemia

• Mistake: Assuming all seizures are epilepsy-related.
• Fix: Always check glucose (BM <3 mmol/L-give 2 mL/kg 10% dextrose IV).

5. Overlooking Meningitis

• Mistake: Assuming all febrile seizures are benign.
• Fix: If child has fever + stiff neck, rash, or focal neurology, consider meningitis and give IV ceftriaxone (80 mg/kg).

Best Practices

1. Pre-Hospital (Parents/First Responders)

• Teach parents: How to time seizures, position safely, and administer buccal midazolam.
• Stock midazolam: Keep a pre-filled syringe in the fridge (stable for 3 months).

2. In Hospital

• Use a seizure protocol: Follow local guidelines (e.g., APLS, NICE).
• Monitor closely: Pulse oximetry, ECG, BP (benzodiazepines can cause hypotension).
• Prepare for intubation: If GCS <8 or respiratory depression, call anaesthetics.

3. Post-Seizure Care

• Neurology referral if:
• Complex febrile seizure (focal, >15 mins, recurrent).
• First afebrile seizure (possible epilepsy).
• EEG/MRI if:
• Focal seizures, developmental delay, or abnormal neurology.

Tools & Frameworks

Real-World Use Cases

1. Pre-Hospital: Paramedic Response

Scenario: A 3-year-old is seizing at home. Parents call 999. Action: - Buccal midazolam (0.3 mg/kg) given by paramedic. - Seizure stops in 4 mins. - Transported to hospital for observation (simple febrile seizure).

2. Emergency Department: Status Epilepticus

Scenario: A 5-year-old arrives still seizing after 10 mins. No IV access. Action: - Buccal midazolam (0.3 mg/kg)-seizure continues. - IO access obtained-lorazepam (0.1 mg/kg IV). - Seizure stops in 2 mins. - Admitted for observation (no second-line needed).

3. Paediatric ICU: Refractory SE

Scenario: A 2-year-old with Dravet syndrome has seizures for 45 mins despite benzodiazepines. Action: - Phenytoin (20 mg/kg IV)-no response. - Levetiracetam (40 mg/kg IV)-no response. - Transferred to ICU-midazolam infusion (0.1 mg/kg/hr) + EEG monitoring. - Seizures controlled after 24h.

Check Your Understanding (MCQs)

Question 1

A 2-year-old (12 kg) has a 5-minute tonic-clonic seizure with fever (39°C). No IV access. What is the first-line treatment?

A) Oral diazepam 5 mg B) Buccal midazolam 3.6 mg C) Intramuscular lorazepam 1.2 mg D) Rectal paracetamol 180 mg

Correct Answer: B) Buccal midazolam 3.6 mg - Calculation: 0.3 mg/kg × 12 kg = 3.6 mg. - Why? Buccal midazolam is first-line for no IV access. - Distractors: - A) Oral diazepam-aspiration risk during seizure. - C) IM lorazepam-slower absorption than buccal. - D) Paracetamol-does not stop seizures.

Question 2

A 4-year-old (16 kg) has seizures for 15 mins despite two doses of buccal midazolam. IV access is now obtained. What is the next step?

A) Repeat buccal midazolam B) Lorazepam 1.6 mg IV C) Phenytoin 320 mg IV over 20 mins D) Paraldehyde PR

Correct Answer: B) Lorazepam 1.6 mg IV - Calculation: 0.1 mg/kg × 16 kg = 1.6 mg. - Why? After two failed benzodiazepine doses, move to IV lorazepam (longer duration). - Distractors: - A) Repeat buccal-not effective after 2 doses. - C) Phenytoin-second-line (used if lorazepam fails). - D) Paraldehyde-third-line (rarely used in modern practice).

Question 3

A 6-month-old has a focal seizure lasting 20 mins with fever. What is the most appropriate next step?

A) Discharge with antipyretics B) Admit for EEG and neurology review C) Give buccal midazolam and observe D) Start phenytoin immediately

Correct Answer: B) Admit for EEG and neurology review - Why? Complex febrile seizure (focal + >15 mins)-higher epilepsy risk. - Distractors: - A) Discharge-misses underlying pathology. - C) Midazolam-seizure already stopped; need investigation. - D) Phenytoin-not indicated for first febrile seizure.

Learning Path

Further Resources

Books

• Paediatric Advanced Life Support (APLS) Manual – Gold standard for emergency management.
• Nelson Textbook of Pediatrics – Comprehensive on seizure disorders.

Courses

• APLS Course (UK/International) – Hands