What is the treatment for an active seizure in a pediatric patient, particularly one with a history of seizures?

Active Pediatric Seizure Treatment

For an active seizure in a pediatric patient, administer benzodiazepines as first-line treatment if the seizure lasts longer than 5 minutes, with lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min as the preferred agent, or midazolam intramuscularly/buccally or diazepam rectally if IV access is unavailable. 1, 2

Immediate Assessment and Stabilization

Position the patient on their side, remove harmful objects from the environment, and protect the head from injury. 1 Never restrain the patient or place anything in the mouth during active seizure activity. 1

• Assess airway, breathing, and circulation immediately while the seizure is ongoing. 1
• Check capillary blood glucose and treat with IV dextrose or IM glucagon if <60 mg/dL (3 mmol/L). 3
• Secure IV access if possible, but do not delay benzodiazepine administration waiting for IV placement. 3

First-Line Pharmacologic Treatment

Any seizure lasting 5 minutes or longer should be treated as status epilepticus, as seizures persisting this long are unlikely to stop spontaneously. 4, 5

Benzodiazepine Options (in order of preference):

• Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min is the first-line treatment for prolonged seizures. 1, 2
• Midazolam intramuscularly (0.2 mg/kg) is preferred over rectal diazepam when IV access is not available. 2, 3
• Buccal or intranasal benzodiazepines (0.2 mg/kg) are recommended over rectal routes for non-IV administration. 3
• Diazepam rectally may be used if other routes are unavailable. 2

Prehospital treatment with benzodiazepines significantly reduces seizure activity compared with waiting until emergency department arrival. 4

Second-Line "Urgent" Therapy

If seizures persist after benzodiazepine administration, proceed immediately to second-line agents: 2, 5

• Fosphenytoin/phenytoin - Note: administration rate should not exceed 2 mg PE/kg/min (or 150 mg PE/min, whichever is slower) in pediatric patients to avoid cardiovascular adverse reactions. 6
• Phenobarbital 2
• Levetiracetam 2
• Valproate sodium 2

Refractory Status Epilepticus

If seizures persist despite first and second-line treatments, initiate continuous infusions of midazolam or pentobarbital and transfer to Pediatric Intensive Care Unit. 2, 5

Critical Monitoring Considerations

• Monitor for respiratory depression, particularly with benzodiazepine administration. 7, 3
• Assisted ventilation may be required in approximately 18% of patients treated with lorazepam. 7
• Monitor vital signs continuously and be prepared for airway management. 5
• Paradoxical excitation occurs in 10-30% of pediatric patients under 8 years of age treated with benzodiazepines, characterized by tremors, agitation, euphoria, and brief visual hallucinations. 7

Special Considerations for Patients with Known Seizure History

• Patients with known epilepsy may have rescue medications prescribed (e.g., rectal diazepam, buccal midazolam). 8
• The treatment algorithm remains the same regardless of seizure history - benzodiazepines are first-line for any seizure lasting >5 minutes. 1, 4
• High seizure burden in children has been associated with poor neurological outcomes, making prompt treatment essential. 9

Common Pitfalls to Avoid

• Do not delay treatment waiting for IV access - use IM, buccal, or intranasal routes immediately. 3
• Do not wait longer than 5 minutes to initiate treatment - early intervention prevents progression to refractory status epilepticus. 4
• Do not use rectal diazepam as first choice when other non-IV routes (IM, buccal, intranasal) are available. 3
• Be aware that lorazepam injection contains benzyl alcohol, which has been associated with serious adverse events in neonates and low-birth-weight infants at high doses. 7
• Emergency department personnel fail to recognize status epilepticus in children in 34% of cases - maintain high clinical suspicion. 4

Post-Seizure Management

• Identify and treat the underlying cause of the seizure (fever, infection, metabolic derangement, etc.). 1, 5
• Consider lumbar puncture in children under 12 months with fever and seizure to rule out meningitis, as meningeal signs may be absent. 10
• Provide parent education and support, as seizures are extremely distressing for families. 8