What is the immediate management for a 3-year-old patient experiencing a seizure?

Immediate Management of Seizure in a 3-Year-Old

For a 3-year-old actively seizing, immediately position the child on their side, ensure high-flow oxygen, check blood glucose, and administer lorazepam 0.1 mg/kg IV/IO (maximum 4 mg) if the seizure lasts beyond 5 minutes or does not self-terminate. 1, 2

Critical First Actions

Immediate Stabilization (First 60 Seconds)

• Position the child on their side in the recovery position to reduce aspiration risk if vomiting occurs 1
• Administer high-flow oxygen immediately to maintain adequate oxygenation and prevent hypoxia 1, 2
• Check blood glucose using point-of-care testing to rule out hypoglycemia as a reversible cause 1, 3
• Do NOT restrain the child or place anything in their mouth during active seizure activity 2

When to Activate Emergency Services

• Any seizure in a child under 6 months requires immediate EMS activation regardless of duration 1
• For children 6 months to 3 years, activate EMS if: seizure lasts >5 minutes, multiple seizures without return to baseline, difficulty breathing, traumatic injury, or failure to return to baseline within 5-10 minutes after seizure cessation 1, 4

Acute Seizure Treatment Protocol

First-Line Medication (If Seizure Continues >5 Minutes)

• Establish IV or intraosseous access immediately to facilitate medication administration 1, 2
• Administer lorazepam 0.1 mg/kg IV/IO (maximum 4 mg per dose) given slowly at 2 mg/min 1, 5
• If seizures persist after 5 minutes, repeat lorazepam (maximum of 2 doses total) 2, 5

Critical Pitfall: The most important risk with lorazepam is respiratory depression—airway patency must be assured and respiration monitored closely, with ventilatory support equipment immediately available 5

Second-Line Treatment (If Seizures Continue After Lorazepam)

• Administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) as a slow infusion over 5-10 minutes 1, 2
• If seizures still persist, add phenobarbital 15-20 mg/kg IV loading dose (maximum 1,000 mg), which achieves therapeutic levels within minutes and controls 77% of seizures in this age group 1, 2

Maintenance Therapy (After Seizure Control)

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

Ongoing Monitoring Requirements

Continuous Assessment

• Monitor oxygen saturation continuously to ensure adequate oxygenation 1, 2
• Assess neurological status using AVPU scale (Alert, responds to Voice, responds to Pain, Unresponsive) or pediatric Glasgow Coma Scale 1, 2
• Check pupillary size and reaction—unilateral sluggish or absent pupillary responses are the most reliable signs of raised intracranial pressure 1, 2
• Monitor for respiratory depression, especially after benzodiazepine and phenobarbital administration 2

Critical Decision Point: Intubation

• Consider elective intubation if the child remains unconscious (Glasgow Coma Score ≤8) to ensure adequate ventilation 1, 2

Post-Seizure Evaluation

Return to Baseline Assessment

• If the child has not returned to baseline within 5-10 minutes after seizure cessation, this warrants emergency medical intervention and possible emergent neuroimaging 3
• Most early seizure recurrences (>85%) occur within 360 minutes (6 hours) of the initial seizure 3

Laboratory Testing

• Order labs based on clinical circumstances rather than routinely: consider if there is vomiting, diarrhea, dehydration, failure to return to baseline alertness, or signs of systemic illness 3
• Immediate laboratory workup should include blood glucose, calcium, magnesium, sodium, complete blood count, and blood culture if infection is suspected 2

Neuroimaging Indications

• Emergent neuroimaging is required if: postictal focal deficit that does not quickly resolve, or child has not returned to baseline within several hours after the seizure 3
• MRI is the preferred imaging modality when neuroimaging is indicated 3

Age-Specific Considerations for 3-Year-Olds

Febrile vs. Afebrile Seizure Distinction

• If fever is present (≥38.0°C), consider febrile seizure but maintain high suspicion for meningitis 1
• For febrile seizures with complex features (prolonged duration, focal features, or multiple episodes), excessive drowsiness, or incomplete recovery within 1 hour, lumbar puncture should be strongly considered 1, 2
• Treat fever with acetaminophen for comfort, but understand this does not prevent seizure recurrence 1

Recurrence Risk

• The overall risk of seizure recurrence after a first unprovoked seizure is approximately 30%, with higher risk in younger children 3

Common Pitfalls to Avoid

• Do not delay treatment waiting for IV access—if IV/IO access cannot be established quickly and seizure continues, intranasal or intramuscular midazolam are acceptable alternatives (though lorazepam IV remains first-line when access is available) 6
• Do not underdose anticonvulsants—studies show 36% of pediatric patients receive incorrect weight-based doses, with 72% receiving lower than recommended doses 6
• Do not assume a brief seizure is benign—any seizure lasting 5 minutes or longer should be considered status epilepticus and treated aggressively, as seizures persisting this long are unlikely to stop spontaneously 4
• Do not perform lumbar puncture in a comatose child or with signs of raised intracranial pressure—obtain brain imaging first 2