Childhood seizures: What you need to know
Pediatric seizures tend to provoke higher anxiety in all of us because they're children in trouble, which can make us feel helpless," says Mary Ann McNeil, BA, EMT-P, Associate Director for the Emergency Medicine Program at the University of Minnesota School of Medicine.
The underlying cause of the seizure can also cause great anxiety, notes McNeil. "For instance, pediatric seizures may be the result of trauma. Couple all this with a child who doesn't communicate at our level and the incident may seem overwhelming," she says.
Assessment of pediatric seizures is key, says Ann Dietrich, MD, FACEP, an emergency physician at Children's Hospital in Columbus, OH. "The most difficult aspect of pediatric seizures is early recognition-especially in infants and diagnosing underlying problems which do respond to therapy," she says.
Here are some tips for assessing and managing seizures in children:
Watch for rhythmic activities in very young children. "The younger the child, the more the brain is set up to be less excitable, that is a baby in the womb spends most of its time sleeping," says Alfred Sacchetti, MD, FACEP, an emergency physician at Our Lady of Lourdes Medical Center in Camden, NJ. "Seizures in newborns and very young children tend to be focal and not generalized because the brain does not conduct erratic impulses as well."
Seizures in young children should be suspected, not by the general tonic clonic activity normally seen in adults, but by rhythmic activities, says Sacchetti. "Anything a child does consistently is suspect to be a seizure, such as winking, shaking just one arm or leg, smacking lips," he warns. "Remember, infants are not coordinated enough to repeat any action accurately. So if a newborn is repeatedly duplicating a motion, think seizure."
Help maintain the airway by a chin lift or mandible thrust maneuver. "Just gently lift the mandible forward from the angles and the airway will open in most children," says Sacchetti. "This is especially useful after the seizure when the child is post ictal."
Make sure child is oxygenated. "The vocal cords will seize and respirations will be compromised as the child tries to breathe or exhale against a closed glottis," Sacchetti explains. "Supplemental oxygen is very effective in keeping this children oxygenated and a pulse oximeter is a very good means to monitor these children."
However, pulse oximeters are only a secondary assessment tool for nurses, stresses McNeil. "Your primary assessment should always be your eyes and brain. The only thing pulse oximetry is able to determine is if there is oxygen in the bloodstream, not if it is being used adequately." Remember that adequate ventilation requires that the patient has good color and adequate chest rise.
Another unique aspect of seizures is that even if the patient is well oxygenated, there may still be brain damage as a result of the toxins released from the repeatedly firing cells, says McNeil. "That is why oxygen alone is not enough. If the patient does not stop seizing within 90 seconds, the caregiver must begin interventions to stop the seizure," she stresses.
Prevent damage from seizure. "There are two general rules for adequately caring for a patient in status epilepticus, says McNeil. "Airway and breathing management and stop the seizure," she notes. "Studies have demonstrated that even with adequate oxygenation, damage from the seizure and its byproducts will continue. That's why the number two goal is to stop the seizure."
Use end tidal CO2 detector for intubated patients. "This monitors carbon dioxide so you can tell when the child is becoming too acidotic from respiratory compromise, if they are retaining too much CO2 from not effectively ventilating," says Sacchetti.
Reassure the family. "Seizures are very frightening, and nurses can reassure the family that even though the child is shaking and looks very scary that in a few minutes it will stop and the child is in no danger," says Sacchetti.
Have appropriate-sized equipment. Be prepared with appropriate sized equipment to support the child's ability to maintain an open airway and adequate ventilation, recommends Nancy Eckle, RN, MEN, CEN, clinical nurse specialist at Children's Hospital in Columbus, OH. "Having an appropriate size bag-valve-mask device and mask to provide assisted ventilations if needed is critically important," she stresses.
Monitor children for reactions to medications. "Medications given to stop seizure often result in respiratory depression, so it is important to monitor the child," says Eckle. "Reassess frequently to assure the child is breathing adequately and maintaining adequate oxygenation."
Be aware of the possibility of respiratory depression. "Drugs such as valium have a very long half life of 48 hours, therefore, respiratory depression continues to be a concern," says McNeil.
Be careful as to the onset of action of various drugs. "Some drugs don't take effect for 15-30 minutes, so if you stack the drugs you may have everything kick in at the same time with disastrous effects," warns Dietrich. "If you choose to give a drug, give an effective dose so it gets the opportunity to work."
Watch for subtle seizure activity. Subtle, generalized seizure activity may go unrecognized by clinicians who are focused on the traditional tonic clonic movements, says McNeil. "When the patient stops tonic clonic movements and the level of consciousness improves, that usually means that the seizure is over and the post ictal phase has begun," she says. "However, sometimes the stopping of these flailing, dramatic movements may simply mean that the patient's muscles are too tired to continue these often exaggerated movements."
Minor movement will continue in that case. "The key to recognizing this is to look for repetitive movement," says McNeil. "It's usually upper body movement such as facial twitching, but can be lower extremities. The hallmark remains repetitive and often slow due to muscle fatigue."
Also watch to see if the patient's level of consciousness is improving. "This can be difficult to assess when we have given anti-seizure drugs that have a sedating effect or respiratory depressant effect," McNeil notes.
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