Fits/seizures and Epilepsy (Children)
⚡ Seizures (“fits”) in children are a common paediatric emergency and vary widely in cause, appearance, and prognosis.
Early recognition, rapid stabilisation, and structured assessment are essential to prevent hypoxia, brain injury, and progression to status epilepticus.
Most childhood seizures are benign (e.g. febrile seizures), but some signal serious underlying pathology.
🚑 Initial Emergency Care (First 5 Minutes)
- 🛫 Airway: Position child in lateral (recovery) position, clear secretions, consider airway adjuncts.
- 🌬️ Breathing: Give high-flow oxygen; monitor saturations.
- ❤️ Circulation: Check pulse, BP, capillary refill; secure IV/IO access early if prolonged.
- 🛡️ Safety: Protect from injury; do not restrain and do not put anything in the mouth.
- ⏱️ Time the seizure: >5 minutes = treat as convulsive status epilepticus.
- 🍬 Glucose: Check capillary glucose early (hypoglycaemia is reversible and dangerous).
📜 Focused History (from carers/witnesses)
- 🧠 Seizure semiology: Onset, duration, focal vs generalised, colour change, incontinence.
- 🔥 Triggers: Fever, recent illness, head injury, sleep deprivation, flashing lights.
- 🧬 Past & family history: Previous seizures, epilepsy, neurodevelopmental disorders.
- 👶 Development: Regression or delay suggests underlying pathology.
- 💊 Medications & vaccines: Missed AEDs, recent new drugs.
🩺 Physical Examination
- 🧠 Neurological: GCS/AVPU, focal deficits, post-ictal state.
- 🌡️ Infection signs: Fever, neck stiffness, bulging fontanelle.
- 🩹 Trauma: Scalp injury, bruising, non-accidental injury red flags.
- 🧬 Skin: Café-au-lait (NF1), ash-leaf spots (tuberous sclerosis).
🧩 Seizure Classification
- 🧠 Focal vs 🌐 Generalised
- 🔥 Provoked (e.g. fever, infection, metabolic) vs ⚡ Unprovoked
🧠 Differential Diagnosis (Common Paediatric Seizures)
| 🧠 Type |
📋 Description |
👶 Age |
🔑 Key Features |
| 🔥 Febrile Seizure |
Seizure triggered by fever without CNS infection |
6 months–5 years |
Generalised, <15 min (simple), no focal signs, excellent prognosis |
| ⚡ Generalised Tonic-Clonic |
Whole-brain involvement |
Any age |
Tonic stiffening → clonic jerks, post-ictal confusion |
| 👀 Absence |
Brief lapses in awareness |
4–14 years |
Staring, eyelid flutter, no post-ictal phase |
| 💥 Myoclonic |
Sudden muscle jerks |
Children/adolescents |
Brief shock-like movements, often morning |
| 👶 Infantile Spasms |
Flexor/extensor spasms |
<1 year |
Clusters, developmental regression, medical emergency |
| 🎯 Focal Seizures |
Arise from one brain region |
Any age |
Motor/sensory/autonomic symptoms ± awareness |
🔬 Investigations (Targeted)
- 🧪 Bloods: Glucose, U&E, Ca²⁺, Mg²⁺, FBC, CRP.
- 🧠 Neuroimaging: MRI/CT if focal signs, trauma, or abnormal neurology.
- 📈 EEG: Helps classify seizure and epilepsy syndrome (not urgent acutely).
- 🧫 Lumbar puncture: If meningitis/encephalitis suspected (after stabilisation).
🚨 Acute Management of Convulsive Seizures (UK Practice)
| ⏱️ Time |
💊 Treatment |
📌 Dose / Notes |
| 0–5 min |
🛡️ ABC + O₂ |
Position child, check glucose, gain IV/IO access |
| ≥5 min |
💉 Benzodiazepine |
• IV lorazepam 0.1 mg/kg (max 4 mg)
• OR buccal midazolam / rectal diazepam if no IV
|
| +5 min (still seizing) |
💉 Repeat benzodiazepine |
Give second dose once only |
| +10–15 min |
🧠 Second-line AED |
• IV levetiracetam or
• IV phenytoin / phenobarbital (specialist advice)
|
| Refractory |
🏥 ICU management |
Intubation, anaesthetic agents, PICU |
💊 Ongoing Management
- 🎯 Treat underlying cause (infection, electrolytes, trauma).
- 📈 Start long-term AEDs for recurrent or unprovoked seizures.
- 🤝 Early neurology referral for infantile spasms, focal seizures, or developmental delay.
- 👨👩👦 Family education: seizure first aid, rescue medications, safety-netting.
📚 Teaching Pearls
- ⏱️ Time defines urgency: >5 minutes = treat.
- 🍬 Always check glucose early.
- 🔥 Simple febrile seizures are benign - reassurance is key.
- 👶 Infantile spasms are a neurological emergency.
- 🧠 EEG is rarely urgent - stabilisation comes first.
