Pediatric emergency medicine trisk 359

The patient’s circulatory status must also be closely monitored. Seizures
generally cause a massive sympathetic discharge that result in hypertension and
tachycardia. Continuous monitoring and intravenous (IV) access should be
obtained. Blood samples, including rapid blood glucose and sodium testing,
should be acquired at this time. Hypoglycemia should be corrected urgently, yet
mild stress hyperglycemia during seizure episode usually does not require
treatment. Peripheral IV access, which is often difficult in the pediatric age group,
may be nearly impossible in the actively seizing patient. Intraosseous and/or
central venous access may be required in the patient with prolonged seizures.
Once the respiratory and circulatory functions have been assessed and
maintained, efforts should be directed at stopping any ongoing seizure activity
and making a diagnosis. As long as adequate ventilation and oxygenation are
maintained, long-term sequelae are unlikely to result from a transient seizure.
Consensus management suggests the initiation of anticonvulsant treatment of
anyone who has been seizing for more than 5 minutes. This likely represents all
patients who are brought to the ED actively seizing.

EVALUATION AND DECISION
History
As a result of the numerous potential causes of seizures, as well as the large
number of events that can be mistaken for a seizure, a focused history is
important. The parent or caregiver needs to carefully describe the episode and the
preceding events. Was there a warning (aura) that the patient was about to have an
event? Was there a loss of consciousness, tongue biting, or incontinence? Did the
event involve the entire body or only a portion? How long did the event last?
How did the patient act after the event was over? The clinician should take into
account that the event characteristics may not be accurately perceived by a
distressed parent. With smartphones and digital media being more common,
parents may present a video clip of the event to the treating clinician, especially
for recurring events.
In addition to the episode itself, the preceding events are also crucial. Was there

a history of trauma, toxin exposure or ingestion, fever, or other systemic signs of
illness (e.g., headache, ataxia, vomiting, diarrhea)? Does the child have an
underlying seizure disorder, history of seizures, or other neurologic problems? Is
the child taking any anticonvulsants? If yes, was there a recent change in dose, or
were any medications started or stopped? Is there a chance that the patient could
have a subtherapeutic level, especially if there were any recently missed doses?


Other questions that should be asked include if there was any other significant
medical history (including abnormal developmental history), any significant
surgical history (including the placement of a ventricular shunt), family history of
seizures, other medication use, and travel history to an endemic region
(neurocysticercosis is one of the leading worldwide causes of seizures).

Planning for an Active Seizure
The pediatric emergency physician should address the possibility of further
seizure during the ED stay, especially in patients with a known seizure disorder
admitted to the ED for a breakthrough seizure. The history should focus on home
medications that need to be administered and/or a possible medication load
during the current visit. An active seizure plan should be addressed. Medication
allergies or past adverse events, status epilepticus episodes in the past, or past
medication failures, can guide the clinician toward a better tailored plan in some
epilepsy patients. Some patients may already have an active seizure/status
epilepticus plan laid out by their primary neurologist.

Physical Examination
With the history, a directed physical examination is performed to look for a
possible cause of the seizure. The examination should not be deferred until a
postictal phase has resolved. While limited in neurologic scope, a timely physical
exam may identify a short-lived Todd paresis and other time-sensitive findings

such as those related to trauma and/or ingestion.
Vital signs, including temperature, should be obtained. An elevated
temperature points to a potential infectious cause. The entire body needs to be
examined for the evidence of trauma, either as a preceding cause or as a result of
falling during the seizure episode. The skin should be examined for rashes or
congenital skin lesions.
Dysmorphic features may be associated with other congenital CNS anomalies.
Stigmata of underlying hepatic, renal, or endocrinologic disorders should also be
noted.
The head should be carefully examined for swelling, deformity, or other signs
of trauma. The presence of a ventricular shunt should be noted. The pupils are
studied for shape, size, reactivity, and equality. The fundi are examined for the
presence of retinal hemorrhages or papilledema. The tympanic membranes are
examined for the presence of hemotympanum or for a source of potential
infection. The mouth should be examined for the evidence of tongue biting.
The neck is assessed for meningeal irritation. If there is a history or other
physical signs of trauma, neck immobilization should be maintained until the C-


spine can be thoroughly examined. Examination of the chest, lungs, and abdomen
is performed in the usual fashion. The extremities are examined for the evidence
of trauma, especially as the result of falling during a seizure.
The neurologic examination may be limited by either ongoing seizure activity
or a postictal state and may consist solely of the pupillary examination, an
assessment of any asymmetric movements (focality), and best response to stimuli.
Any abnormal posturing (decerebrate or decorticate) should be noted and dealt
with immediately, with emergent imaging and possibly neurosurgical
intervention. During the postictal state, presence of a Todd paresis should be
recorded.
If there is a question of a possible ingestion, the examination is also directed at

uncovering a potential toxicologic syndrome (toxidrome) that may suggest a
specific class of drugs or toxins that are responsible for the seizure (see Chapter
102 Toxicologic Emergencies ). Important variables include temperature, heart
rate, blood pressure, pupil size, sweating, flushing, and cyanosis.
As the patient recovers from the seizure episode, periodic reassessment is
needed to assess for any underlying neurologic abnormalities.

DIAGNOSTIC APPROACH
Once it has been determined that a seizure may have taken place, the initial
diagnostic evaluation (Fig. 72.1 ) starts with the history and physical examination.
Laboratory, radiologic, and other neurodiagnostic testing (e.g., EEG) are other
tools that can be a part of the seizure evaluation.
Patients with obvious trauma who are seizing should be treated per advanced
trauma life support (ATLS) guidelines (see Chapter 7 A General Approach to the
Ill or Injured Child ), with close attention to possible intracranial injury (see
Chapter 113 Neurotrauma ). Often, patients with a known seizure disorder will
present to the ED actively seizing. Patients known or suspected to be taking
anticonvulsants should have drug levels evaluated. A subtherapeutic
anticonvulsant level is among the most common reasons for patients to present
with seizures. At times, a concurrent mild infectious process (URI, diarrhea) may
have an effect on both seizure threshold and/or anticonvulsant
absorption/metabolism.
Many different laboratory tests may reveal a cause for a seizure and, as a result,
suggest a potential treatment. A rapid glucose reagent strip test should be
performed with the initial blood sample. Hypoglycemia is a common problem
that can often precipitate seizure activity. If hypoglycemia is documented or a
rapid assessment is not available, treatment with 0.25 to 1 g/kg of dextrose is


indicated. Normal glucose levels should not necessarily be used to exclude

hypoglycemia as the seizure cause as secondary stress hyperglycemia may occur
over time as the seizure progresses. Hyponatremia is a relatively common cause
of seizures in infants, so a bedside rapid sodium test should be performed.
A febrile seizure is defined as a seizure caused by a fever, but this is a
diagnosis of exclusion. While the formal definition of the International League
Against Epilepsy considers age range for febrile seizures to be 1 month to 7
years, most of the published data and PEM approach are limited to those 6
months to 5 years of age. Caution should be used in labeling someone as having a
febrile seizure outside of this age range. Other infectious etiologies that present
with a fever and can be the direct cause of a seizure (e.g., meningitis) must first
be ruled out clinically. Routine performance of a lumbar puncture (LP) for
patients with either simple or complex febrile seizure is not required (see
Chapters 31 Fever and 94 Infectious Disease Emergencies ) but rather is based on
clinical findings. Furthermore, infections not involving the CNS may still be the
cause of the seizure through the elaboration of fever and inflammatory mediators.
Presence of fever and/or an elevated white blood cell (WBC) count may direct
one to look for a potential infectious cause, yet stress response with peripheral
leukocytosis occurs in up to a quarter of children with generalized seizures. Blood
cultures should be limited to those patients at risk for bacteremia. Urinalysis and
chest radiographs can also be used to confirm a source of infection.