Not all pediatric seizures are epilepsy or febrile. Sometimes, the culprit is hidden in the bloodwork. Metabolic disturbances are reversible causes of seizures — but only if rookies remember to check for them.
Why It Matters
- Seizures may be the first sign of metabolic derangement.
- Treating the seizure without correcting the cause = recurrence.
- Some causes (hypoglycemia, hypocalcemia) can be rapidly fatal if missed.
Key Metabolic Disturbances That Cause Seizures
1. Hypoglycemia
- One of the most common and easily reversible.
- Check glucose immediately in every seizing child.
- Treat if <60 mg/dL: D10 (2–4 mL/kg IV/IO).
2. Hyponatremia
- Often due to gastroenteritis, water intoxication, SIADH.
- Symptoms: irritability, lethargy, seizures.
- Severe (<120 mmol/L) → seizures, coma.
- Treat: hypertonic saline 3% (2 mL/kg IV over 10–20 min).
3. Hypocalcemia
- Neonates (vitamin D deficiency, maternal diabetes).
- Presents with tetany, jitteriness, seizures.
- Treat: calcium gluconate 10% (0.5–1 mL/kg IV slowly).
4. Hypomagnesemia
- Often with hypocalcemia.
- Treat: magnesium sulfate 50% solution (0.2 mL/kg IV).
5. Hypernatremia / Hyperglycemia
- Less common but can cause seizures due to osmotic shifts.
- Correct slowly to avoid cerebral edema.
6. Uremia / Hepatic Encephalopathy
- Seen in chronic disease or acute organ failure.
- Consider if history of renal/hepatic disease.
Step 1: ED Evaluation
- ABCs first.
- Fingerstick glucose immediately.
- Draw labs:
- Electrolytes (Na, K, Ca, Mg).
- Glucose.
- BUN, creatinine, LFTs.
- CBC, cultures if infection suspected.
- Consider toxicology if ingestion possible.
Step 2: ED Management
- Stop the seizure with benzodiazepines if >5 min.
- Correct the underlying cause immediately.
- Avoid rapid overcorrection (Na, glucose) — risk of osmotic demyelination or cerebral edema.
- Admit if unstable, metabolic cause not rapidly reversible, or unclear diagnosis.
Red Flags for Metabolic Cause
- Seizures in neonates or infants.
- Seizures without fever in previously healthy child.
- Seizures resistant to benzodiazepines.
- Recurrent seizures in short time frame.
- Associated systemic symptoms (vomiting, diarrhea, dehydration).
Common Rookie Mistakes
- Forgetting to check glucose right away.
- Treating seizures with AEDs alone — ignoring metabolic workup.
- Overcorrecting sodium too fast.
- Discharging after seizure stops without finding underlying cause.
Rookie Pearls
- Glucose, sodium, calcium, magnesium = “seizure panel” in every child.
- Correct cause + treat seizure = lasting solution.
- If unsure, admit — metabolic seizures can recur suddenly.
- Always consider ingestion or toxin in unexplained seizures.
Take-Home Message
Pediatric seizures are not always epilepsy or febrile. For rookies:
- Always check glucose and electrolytes.
- Correct abnormalities carefully and promptly.
- Admit unstable or unexplained cases.
Remember: In children, a simple lab test can stop a lifetime of seizures — don’t skip it.
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