What is the treatment for convulsions in pediatric patients?

Treatment of Convulsions in Pediatric Patients

Benzodiazepines are the first-line treatment for acute convulsions in pediatric patients, with intravenous lorazepam (0.1 mg/kg, maximum 4 mg) being as effective as diazepam and having a better safety profile. 1, 2

Initial Management of Acute Convulsions

First-Line Therapy

1. Benzodiazepines:

   • IV Lorazepam: 0.1 mg/kg (maximum 4 mg) 1, 3
   • IV Diazepam: 0.2 mg/kg 1
   • Intranasal Lorazepam: 0.1 mg/kg (if IV access unavailable) 4
   • IM Midazolam: Effective alternative when IV access is difficult 2

2. Monitoring during administration:

   • Continuous pulse oximetry to monitor oxygen saturation 5
   • Capnography to detect respiratory depression early 5
   • Monitor for respiratory depression (occurs in 4-6% of patients) 1

Second-Line Therapy (if seizures continue after benzodiazepines)

1. Phenytoin/Fosphenytoin:

   • Dose: 18-20 mg/kg IV 5, 6
   • Administer at maximum rate of 1-2 mg/kg/min to avoid cardiovascular side effects 6
   • Fosphenytoin preferred over phenytoin due to better tolerability 2

2. Phenobarbital:

   • Dose: 10-20 mg/kg IV 5
   • Monitor for respiratory depression and hypotension 5

3. Valproic Acid:

   • Dose: 20-30 mg/kg IV 7
   • Good option for patients with hypotension 5

Management of Refractory Status Epilepticus

If seizures continue after first and second-line therapies:

1. High-dose Phenytoin: Up to 30 mg/kg 5

2. Continuous Infusion Options:

   • Midazolam infusion 5
   • Pentobarbital infusion: Effective in 92% of refractory cases but causes hypotension in 77% 5
   • Propofol infusion: Consider in older children 5

Special Considerations for Febrile Seizures

1. Treatment of fever:

   • Paracetamol (acetaminophen) is preferred 5
   • Ensure adequate fluid intake 5
   • Avoid physical cooling methods like cold bathing or tepid sponging 5

2. Diagnostic considerations:

   • Lumbar puncture indicated if:
     • Clinical signs of meningitis present
     • Complex febrile seizure
     • Child is unduly drowsy, irritable, or systemically ill
     • Age less than 18 months (especially under 12 months) 5
   • Measure blood glucose in any child still convulsing or unrousable 5

3. Parent education:

   • Explain nature of febrile convulsions
   • Provide instructions on fever management
   • Consider teaching parents to administer rectal diazepam for prolonged seizures 5

Monitoring and Follow-up

1. Post-seizure monitoring:

   • Monitor vital signs until fully recovered
   • Observe for at least 1 hour after complex seizures 5
   • Check for return to baseline mental status 8

2. Follow-up considerations:

   • Risk of recurrence after first febrile seizure is approximately 30% 5
   • Risk factors for recurrence: younger age at first seizure, family history 5
   • Risk of subsequent epilepsy after simple febrile seizure is only about 2.5% 5

Common Pitfalls to Avoid

1. Respiratory depression: Benzodiazepines can cause respiratory depression, but untreated seizures pose a greater risk 2

2. Delayed treatment: Prolonged seizures increase risk of neurological damage; treatment should be initiated promptly

3. Inadequate dosing: Underdosing first-line agents may lead to treatment failure and need for additional medications

4. Overlooking underlying causes: Always consider and investigate potential underlying causes, especially in first-time seizures

5. Excessive diagnostic testing: EEG is not routinely indicated after a single febrile seizure 5

6. Medication interactions: Be aware that enzyme-inducing antiepileptic drugs may interact with other medications 7