A seizing child in the ED is one of the scariest scenarios for rookies. Parents are panicked, staff look to you for direction, and seconds feel like hours. The good news: most pediatric seizures are self-limited, but knowing the first steps is critical to prevent complications.
Step 1: Recognize Common Types
- Febrile seizures (most common, age 6 mo–5 yrs).
- Epileptic seizures (known epilepsy, missed meds, breakthrough).
- Provoked seizures (hypoglycemia, trauma, infection, toxins, electrolyte imbalance).
- Status epilepticus (seizure >5 min, or recurrent without recovery).
Step 2: Immediate ED Actions (ABCs First)
- Airway: place child in lateral position, suction secretions, prepare for intubation if prolonged or refractory.
- Breathing: give oxygen, monitor SpO₂.
- Circulation: establish IV/IO access, monitor BP, HR, attach to monitors.
- Don’t put anything in the mouth — no tongue blades or oral airways during seizure.
Step 3: Check Glucose Early
- Hypoglycemia is a common, reversible cause.
- Treat immediately if glucose <60 mg/dL:
- Dextrose 10% (2–4 mL/kg IV/IO bolus).
- Give thiamine if malnourished.
Step 4: First-Line Treatment (If Seizure >5 min)
- Benzodiazepines:
- Lorazepam 0.1 mg/kg IV (max 4 mg).
- Midazolam 0.2 mg/kg IM/IN/IV (max 10 mg).
- Diazepam 0.2–0.5 mg/kg IV/rectal (max 10 mg).
- Repeat once after 5–10 min if still seizing.
Step 5: Second-Line (If Seizure Persists)
- Levetiracetam: 60 mg/kg IV (max 4500 mg).
- Valproic acid: 20–40 mg/kg IV.
- Fosphenytoin: 15–20 mg PE/kg IV.
- Escalate to ICU and continuous EEG if refractory.
Step 6: Consider Underlying Cause
- Fever? → febrile seizure.
- Infection? → meningitis/encephalitis workup.
- Trauma? → CT head.
- Electrolytes? → Na, Ca, Mg.
- Toxins/ingestions? → tox screen if suspicion.
Step 7: Disposition
- Admit if: status epilepticus, recurrent seizures, abnormal neuro exam, underlying pathology.
- Discharge if: simple febrile seizure, back to baseline, reliable caregivers, no red flags.
Common Rookie Mistakes
- Waiting too long before giving benzos (>5 min).
- Giving inadequate benzo dose (underdosing is common).
- Not checking glucose right away.
- Rushing to intubate without trying benzos first.
- Discharging complex febrile seizures (focal, prolonged, recurrent) without neurology input.
Rookie Pearls
- “Time is brain” applies to kids too — treat >5 min seizures promptly.
- IM midazolam is safe and effective if IV access delayed.
- Always reassure parents — seizures are terrifying but often benign.
- Document seizure description (generalized vs focal, duration, recovery).
Take-Home Message
Pediatric seizures in the ED are high-stress but manageable with a structured approach:
- ABCs + glucose check first.
- Benzos at 5 minutes.
- Escalate if seizure persists.
- Always look for underlying triggers.
Remember: Most pediatric seizures stop on their own — your job is to keep the child safe, treat promptly if prolonged, and find the cause.
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