What is the initial management for a pediatric patient presenting with seizures and abnormal pupillary reflex?

Initial Management of Pediatric Seizures with Abnormal Pupillary Reflex

In a pediatric patient presenting with seizures and abnormal pupillary reflex, immediately secure the airway with high-flow oxygen, check bedside glucose, establish IV/IO access, and administer lorazepam 0.1 mg/kg IV while simultaneously assessing for life-threatening causes including raised intracranial pressure, structural brain lesions, and metabolic derangements. 1, 2

Immediate Stabilization (First 0-5 Minutes)

Airway and Vital Functions

• Assess and secure the airway immediately using the CAB (Circulation, Airway, Breathing) approach, positioning the infant in a "sniffing" position to maintain airway patency 1, 2
• Administer 100% high-flow oxygen to prevent hypoxia, as respiratory compromise is common during seizures 1, 2
• Monitor oxygen saturation continuously and prepare for potential intubation if the patient remains unconscious (Glasgow Coma Score ≤8) 1

Critical Bedside Assessment

• Check blood glucose immediately at the bedside—hypoglycemia is a rapidly reversible cause of seizures that must not be missed 1, 2
• Establish IV or intraosseous access without delay for medication administration 1, 2
• Monitor vital signs including blood pressure and temperature continuously 1, 2

Pupillary Assessment and Its Significance

Technique and Interpretation

• Assess pupil size, shape, symmetry, and direct light response in both eyes 3
• Perform the swinging-light test to detect a relative afferent pupillary defect (RAPD): shine a penlight in one eye for <5 seconds, then quickly swing to the other eye; abnormal pupillary dilation when light is shined on that eye indicates an afferent defect 3

Critical Warning Signs

• Unilateral sluggish or absent pupillary response is the most reliable sign of raised intracranial pressure—this demands emergent neuroimaging 1
• A relative afferent pupillary defect suggests unilateral optic nerve or anterior visual pathway pathology 3
• Pupillary asymmetry >1 mm is clinically significant and warrants investigation 3

Important caveat: Pupillary evaluation in children can be challenging due to frequent shifts in fixation and focusing, but abnormal findings should never be dismissed 3

Seizure Management Protocol

First-Line Treatment (0-5 Minutes)

• Administer lorazepam 0.1 mg/kg IV (maximum 2 mg per dose) slowly over 2 mg/min 1, 2, 4
• May repeat once after at least 1 minute if seizures persist (maximum of 2 doses total) 1, 2
• Critical warning: Have airway equipment immediately available, as respiratory depression is the most important risk with lorazepam 4

Second-Line Treatment (5-10 Minutes)

• If seizures continue after benzodiazepines, immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) given slowly over 5-10 minutes 1, 2
• Alternative: Fosphenytoin 18-20 mg PE/kg IV at maximum rate of 2 mg PE/kg/min (or 150 mg PE/min, whichever is slower) 2

Third-Line Treatment (>20 Minutes - Refractory Status)

• Add phenobarbital 10-20 mg/kg IV (maximum 1,000 mg) for seizures persisting beyond 20 minutes 1, 2
• Initiate continuous EEG monitoring 2
• Transfer to Pediatric Intensive Care Unit for ongoing management 2
• Monitor closely for respiratory depression, especially with combination therapy 2, 4

Urgent Diagnostic Workup

Laboratory Studies

• Blood glucose, calcium, magnesium, sodium 1
• Complete blood count and blood culture if infection suspected 1
• Consider toxicology screening if drug exposure or substance abuse is possible 3

Neuroimaging Indications

Emergent CT or MRI is indicated when:

• Abnormal pupillary reflex suggesting raised intracranial pressure or focal lesion 1
• Postictal focal neurological deficit that does not quickly resolve 3
• Patient has not returned to baseline within several hours after seizure 3
• First-time focal seizure 3

MRI is preferred over CT for definitive imaging, but CT may be necessary initially in unstable patients to guide early therapeutic decisions 3

High-Risk Features Requiring Imaging

• Presence of predisposing neurological condition 3
• Focal seizure semiology 3
• Abnormal neurological examination 3
• Cognitive or motor impairment of unknown etiology 3

Maintenance Therapy After Seizure Control

Once seizures are controlled:

• Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1, 2
• Levetiracetam 15-30 mg/kg IV every 12 hours (maximum 1,500 mg) 1, 2
• Phenobarbital 1-3 mg/kg IV every 12 hours if used 1

Critical Pitfalls to Avoid

• Never restrain the infant during seizures or place anything in the mouth 1
• Do not delay second-line therapy—seizure responsiveness to treatment is time-dependent 5, 6, 7
• Avoid excessive fosphenytoin infusion rate, which can cause cardiovascular collapse 2
• Do not miss hypoglycemia by failing to check glucose early 1, 2
• Monitor for prolonged sedation, especially in patients >50 years or with multiple doses, as sedative effects may add to post-ictal impairment 4
• Equipment for airway management and ventilatory support must be immediately available at all times 1, 4

Special Consideration: Underlying Etiology

The combination of seizures with abnormal pupillary reflex should prompt consideration of:

• Hypoxic-ischemic encephalopathy 1
• Intracranial hemorrhage or structural lesion 1
• Raised intracranial pressure 1
• Perinatal ischemic stroke 1
• CNS infection (meningitis/encephalitis) 3, 1
• Metabolic disorders 1

Lumbar puncture should be performed if there is concern for meningitis or encephalitis, but is of limited value otherwise in first non-febrile seizures 3