Perform a stat sodium and glucose level in patients with refractory seizures
Perform a stat sodium and glucose level in patients with refractory seizures: Excerpt from Avoiding Common Pediatric Errors
Author:
Caroline Rassbach, MD
What to Do - Interpret the Data
Seizures are one of the most common neurologic conditions affecting children. The majority are short, self-limited seizures that occur secondary to
disorders originating outside the brain. Examples include high fever, infection, head trauma, hypoxia, and toxins. Less than one third of seizures in
children occur as a result of epilepsy. When a child presents with a first-time
seizure, or when a child with a known seizure disorder presents with prolonged seizure, metabolic causes should be considered. Obtaining stat serum
glucose and sodium levels are essential in these children.
Initialassessmentofanychildwithaseizureshouldincludeevaluationof
the airway, breathing, and circulation (ABCs). The provider should perform
vital signs and place the patient on a cardiac monitor and on supplemental
oxygen. The provider should then obtain a detailed history and perform a
quick physical examination, including a neurologic examination, searching
for clues to the etiology of the seizure. Life-threatening conditions, such as
meningitis, sepsis, head trauma, and toxin ingestion, should be considered
in the differential diagnosis.
When a seizure lasts >5 minutes, intravenous access should be attained
and stat serum glucose and sodium levels drawn. Serum calcium, phosphorus, magnesium, blood urea nitrogen, and a complete blood count may also
be indicated. Urine for toxicology and serum anticonvulsant levels may be
helpful. A benzodiazepine such as lorazepam or a barbiturate should be administered as a first-line drug to stop the seizure. Lorazepam administration
can be repeated every 10 to 15 minutes if needed.
If the seizure continues for >10 minutes, a second anticonvulsant, such
as phenobarbital or phenytoin, should be administered. Metabolic derangements, such as hypoglycemia and hyponatremia, should be treated as soon
as they are diagnosed.
When the seizure activity persists >30 minutes, it is referred to as status epilepticus. Administration of a second long-acting anticonvulsant is
indicated for status epilepticus. In addition, the practitioner should prepare
for intubation and general anesthesia as the seizure approaches 45 minutes.
Complications of status epilepticus include hypoxia, lactic acidosis, hyperkalemia, hypoglycemia, shock, hyperpyrexia, renal and respiratory failure,
and death.
Hypoglycemia and hyponatremia are the most frequent metabolic derangements that cause seizure. Hypoglycemia occurs most commonly in
neonates in the setting of hypoxia, toxemia, gestational diabetes, or a normal
delivery. In older children, it occurs because of prolonged fasting, malabsorption and malnutrition, systemic disease, and hyperinsulinemia. Hypoglycemia in infants presents as cyanosis, apnea, hypothermia, hypotonia,
poor feeding, lethargy, or seizures. In older children, signs of hypoglycemia
includeanxiety,tachycardia,sweating,tremulousness,weakness,hunger,and
seizures. At any age, hypoglycemia should be considered as a cause of a
seizure.Seizuressecondarytohypoglycemiashouldbetreatedwith2mL/kg
of 50% glucose intravenously.
Hyponatremia, another metabolic cause for seizure, is one of the
most common electrolyte disturbances occurring in hospitals. It usually
results from excess free water intake in the presence of impaired free
water excretion. Examples include syndrome of inappropriate secretion
of antidiuretic hormone (SIADH), postoperative hyponatremia, water intoxication, overdilution of infant formula, and diuretic use. When hyponatremia occurs, water shifts into the intracellular space, resulting in
cellular swelling. This may present clinically as cerebral edema and encephalopathy with headache, nausea, vomiting, emesis, and weakness. It may
progress to altered mental status, seizures, respiratory arrest, and cerebral
herniation.
Symptomatic hyponatremia is a medical emergency and should be
treated with hypertonic 3% saline intravenously. For seizing patients or
for those with increased intracranial pressure, the hypertonic saline should
be infused rapidly enough to raise the serum sodium level by 4 to 8 mEq/L
during the first hour or until seizure activity ceases. For less severe symptoms, hypertonic saline should be infused with a goal of raising the serum
sodium by 1 mEq/L/hr. In general, 1 mL/kg of hypertonic saline will raise
the serum sodium level by 1 mEq/L. Practitioners should be aware that
overly fast correction of hyponatremia can result in devastating cerebral
demyelination.
Practitioners should remember to consider metabolic derangements
in patients with seizures. Stat serum glucose and sodium levels should be
checked for all patients with prolonged or refractory seizures.
Suggested Readings
Johnston MV. Seizures in childhood. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson
Textbookof Pediatrics. 17thed.Philadelphia: Saunders;2004: chapter586,pages1993–2009.
Moritz ML, Ayus JC. Disorders of water metabolism in children: hyponatremia and hypernatremia. Pediatr Rev. 2002;23(11):371–380.
Sabo-Graham T, Seay AR. Management of status epilepticus in children. Pediatr Rev.
1998;19(9)306–310.
SperlingMA.Hypoglycemia.In:BehrmanRE,KliegmanRM,JensonHB,eds.NelsonTextbook
of Pediatrics. 17th ed. Philadelphia: Saunders; 2004: - .
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
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