Case study: How would you manage this seizure?

While playing with his older brother, an 18-month-old boy suddenly went rigid, turned blue, fell backward, and experienced generalized tonic-clonic seizures. The child’s mother and grandparents scooped him up and rushed to a nearby emergicenter. While applying oxygen and starting initial management, clinic personnel called 911, says Laura M. Criddle, MS, RN, CS, CEN, CCRN, CNRN, emergency, trauma, and neurological clinical nurse specialist at Oregon Health and Sciences University in Portland.

On the way to the hospital, paramedics established vascular access through an intraosseous line, administered diazepam, and orally intubated and manually ventilated the child. Approximately 15 minutes after onset, the boy arrived in the ED still actively seizing, recalls Criddle. "Despite phenytoin loading and multiple doses of lorazepam and phenobarbitol, intermittent seizure activity continued, and there was no return of consciousness," she says.

In the ED, nurses elicited a history from the family and were told that the child had no chronic medical problems, no history of trauma, took no medications, and had been healthy and behaving normally all day, says Criddle. "He was afebrile, up-to-date on his immunizations, had never previously had a seizure, and had no family seizure history," she adds.

According to Criddle, the ED work-up consisted of the following:

  • A computerized tomography scan of the head was done to identify trauma, anoxic injury, intracerebral masses, or bleeding.
  • Serum and urine toxicologic screens were done to detect possible poisoning.
  • Glucose and electrolyte levels were drawn to look for abnormalities.
  • A lumbar puncture was performed to rule out meningitis or a subarachnoid hemorrhage.

"Nurses also assessed the patient and his family for any indications of nonaccidental trauma," she adds.

Preliminary results of all studies and questioning gave no clue as to what caused the seizure, says Criddle. She adds that since there was little evidence of improvement, arrangements were made for the child to be transferred to a regional pediatric center for magnetic resonance imaging, intensive care unit admission, neurologic consultation, and continuous electroencephalagram monitoring. Five days and many seizures later, the boy was discharged home. He was sleepy from the medications, but without any obvious neurological deficits, says Criddle. "No cause for his seizures was ever determined," she reports.

Criddle notes that the pediatric brain is remarkably resilient, and a single episode of seizures does not necessarily indicate the presence of an epileptic condition that will result in an ongoing seizure disorder. "This was the case with this boy, who has developed normally and has remained off medications and seizure-free for the past seven years," she reports.