What is the recommended treatment for a post-seizure pediatric patient?

Post-Seizure Pediatric Management

After a pediatric seizure, immediately assess airway, breathing, and circulation (CAB), provide high-flow oxygen, check bedside glucose to rule out hypoglycemia, and monitor vital signs continuously while determining if the seizure was self-limited or requires ongoing treatment. 1, 2

Immediate Post-Seizure Assessment

The priority in the immediate post-seizure period is stabilization and identifying reversible causes:

• Secure the airway and provide 100% oxygen to prevent hypoxia, which is critical in all pediatric seizure patients 1
• Check blood glucose immediately at bedside to identify hypoglycemia as a rapidly reversible cause 1, 2, 3
• Establish IV or intraosseous access for medication administration if not already present 1
• Monitor vital signs and oxygen saturation continuously throughout the post-ictal period 4, 1

Treatment Decision Algorithm

For Self-Limited Seizures (Single, Brief Episode)

If the seizure was a single, self-limiting event occurring at onset or within 24 hours of acute illness (such as stroke), do NOT initiate long-term anticonvulsant medications. 4

• Simple febrile seizures require no prophylactic anticonvulsant therapy, as antipyretics are ineffective in preventing recurrence 4, 1
• Provide reassurance and education to caregivers about febrile seizure management 1
• Observe the child for 24 hours and follow local standards for fever management 4

For Ongoing or Recurrent Seizures

If seizures continue or recur in the post-ictal period, treat as active status epilepticus:

First-line treatment: Administer lorazepam 0.1 mg/kg IV (maximum 2 mg) slowly, which may be repeated once after at least 1 minute (maximum of 2 doses) 1, 3

• Lorazepam is preferred over diazepam based on American Academy of Pediatrics recommendations, though recent evidence shows equivalent efficacy 1, 5
• Be prepared for respiratory depression, especially when combined with other sedative agents 4, 1

Second-line treatment (if seizures persist): Immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) 1, 3

• Alternative: Fosphenytoin 18-20 mg PE/kg IV at a maximum rate of 2 mg PE/kg/min (or 150 mg PE/min, whichever is slower) 1, 6
• Critical pitfall: Excessive fosphenytoin infusion rate can cause cardiovascular collapse 1, 6

Third-line treatment (seizures >20 minutes): Add phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) and initiate continuous EEG monitoring 1, 3

• Transfer to Pediatric Intensive Care Unit (PICU) for ongoing management 1, 3

Maintenance Therapy After Seizure Control

Once seizures are controlled, consider maintenance dosing:

• Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1, 3
• Levetiracetam 30 mg/kg IV every 12 hours or increase to 20 mg/kg IV every 12 hours (maximum 1,500 mg) 1, 3

Special Populations

Complex Febrile Seizures

• Observe within an inpatient setting 4
• Perform investigations including blood tests and lumbar puncture as appropriate to determine underlying etiology 4
• Prophylactic intermittent diazepam during febrile illness may be considered for recurrent or prolonged complex febrile seizures, but NOT for simple febrile seizures 4

Neonatal Seizures

• Follow the same CAB assessment, oxygen administration, and glucose checking protocol 2
• Withdrawal-associated seizures in neonates are primarily myoclonic, respond to opiates, and carry no increased long-term risk 2

Critical Pitfalls to Avoid

• Inadequate respiratory monitoring when using benzodiazepines, particularly with combination therapy 1, 3
• Failure to check glucose early can lead to missed diagnosis of easily reversible hypoglycemia 1, 3
• Delaying second-line therapy beyond 5-10 minutes worsens seizure outcomes 1
• Using prophylactic anticonvulsants for simple febrile seizures causes unnecessary toxicity without benefit 4, 1
• Prophylactic anticonvulsants after single unprovoked seizures are not recommended and may impair neural recovery 4

Long-Term Considerations

• Antiepileptic drugs should NOT be routinely prescribed after a first unprovoked seizure 4
• For established epilepsy, discontinuation of antiepileptic drugs should be considered after 2 seizure-free years, with involvement of patient and family in decision-making 4
• EEG and neuroimaging should not be used routinely for diagnosis in non-specialized settings but may be appropriate in specialized facilities for etiological diagnosis 4