Prolonged febrile seizure with no IV access
An EMS crew brings 3-year-old Owen to the emergency department at 10:42. His mother reports he was febrile and drowsy, then had a generalized tonic-clonic seizure at 10:33 that has not stopped. He has no IV access. He weighs 14 kg by length-based tape; his mother says he was 13.6 kg at his 3-year checkup last month. He is breathing but has sonorous respirations, SpO2 91% on room air, heart rate 152, and a temperature of 39.2°C. The ED orders read: lorazepam 0.1 mg/kg IV every 5 minutes as needed, maximum 2 doses; midazolam 0.2 mg/kg IM if no IV access; and levetiracetam 60 mg/kg IV for refractory seizures. The pharmacy stocks lorazepam 2 mg/mL, midazolam 5 mg/mL, and levetiracetam 100 mg/mL. Owen has no known allergies and is up to date on immunizations. His last meal was 2 hours ago.
1. State your priorities in the first 5 minutes, including drug calculations for the available routes.
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Call for help, note time zero, position Owen on his side, suction the sonorous secretions, give oxygen, and monitor SpO2, heart rate, and glucose. Do not force anything into his mouth. Because there is no IV, give midazolam 0.2 mg/kg IM: 0.2 × 14 = 2.8 mg, which at 5 mg/mL is 0.56 mL, in the anterolateral thigh per policy. If IV access is obtained first, give lorazepam 0.1 mg/kg = 1.4 mg, or 0.7 mL of 2 mg/mL, with a maximum of two doses. Reassess every few minutes and prepare a second benzodiazepine dose at 5 minutes if the seizure continues. Check glucose and temperature. The fever matters, but it does not delay the benzodiazepine. Document the seizure start time, the drug, dose, route, and response, and have bag-mask, suction, and airway equipment ready because benzodiazepines can cause respiratory depression. Use the measured 14 kg for dosing and document the source of the weight.
2. Two benzodiazepine doses have been given and the seizure is still ongoing at 15 minutes. What do you do next?
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This is refractory status epilepticus, so escalate. Give levetiracetam 60 mg/kg = 840 mg; at 100 mg/mL that is 8.4 mL, infused over about 15 minutes per protocol. A protocol alternative is fosphenytoin 20 mg PE/kg. Call anesthesia or the PICU, prepare for airway management and possible intubation, and anticipate hypotension and respiratory depression from the benzodiazepines. Continue oxygen, suction, and monitoring, recheck glucose, and consider electrolytes and toxicology. Do not give a third benzodiazepine without a plan. Document the sequence, times, and response. Once the seizure stops, assess for meningeal signs and the source of fever. A 3-year-old with a prolonged febrile seizure may need further evaluation, including consideration of lumbar puncture if meningitis is a concern, and empiric antibiotics if signs are present. Keep the mother informed at each step.
3. What postictal care and family teaching would you provide once the seizure stops?
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Place Owen in the recovery position, suction as needed, give oxygen, monitor, recheck glucose and temperature, and let him wake in a quiet, dim area with his mother present. Explain in plain language what happened, what was given, and what comes next, and use teach-back. Antipyretics treat discomfort but do not prevent febrile seizures, so do not promise that fever control will stop them. Teach seizure first aid: time the seizure, protect the head, do not restrain the child or put anything in the mouth, and call 911 if it lasts more than 5 minutes or breathing is abnormal. Disposition depends on cause: if he returns to baseline with a simple febrile seizure, home with follow-up may be appropriate; if the seizure was prolonged or focal, or meningitis is a concern, admit and evaluate. Document the teaching and the family's understanding.