Pediatric emergency medicine trisk 653

associated with tonic posturing. The episode lasts only a few seconds, and
afterward, the child resumes normal activity. Acute dystonia, usually seen as a
side effect of certain medications, can mimic a tonic seizure. The child having a
dystonic reaction, however, does not lose consciousness and has no postictal
drowsiness.
Several paroxysmal events are associated with sleep. Night terrors (see Chapter
126 Behavioral and Psychiatric Emergencies ) usually begin in the preschool
years. The sleeping child wakes suddenly, is confused and disoriented, and
appears frightened, often screaming and showing signs of increased autonomic
activity (tachycardia, tachypnea, sweating, dilated pupils). Such episodes
typically last only a few minutes, and the child does not usually recall the event.
Benign myoclonus is characterized by self-limited episodes of sudden jerking of
the extremities, usually upon falling asleep. There is no alteration of
consciousness. In sleep paralysis, there is a transient inability to move during the
transition between sleeping and waking, also with no change in the level of
consciousness.
Pseudoseizures are occasionally seen, often in patients with an underlying
seizure disorder or in patients who have a relative with epilepsy. Some features
suggestive of pseudoseizures are suggestibility; lack of coordination of
movements; moaning or talking during the seizure; lack of incontinence,
autonomic changes, or postictal drowsiness; response to painful stimuli; and poor
response to treatment with anticonvulsant agents.
The most important diagnostic test in distinguishing nonepileptic events from
seizures is a careful history, including a detailed description of the event from the
person who witnessed it. In atypical or unclear cases, referral for
electroencephalogram (EEG) or video EEG monitoring may help in establishing
the diagnosis.
Clinically, seizures may be divided into partial (also termed focal) and
generalized seizures ( Table 97.2 ), and partial seizures are further classified as
complex or simple. Complex partial seizures imply impaired consciousness.
Generalized tonic–clonic seizures (previously called grand mal seizures ) are the

type most often seen in acute pediatric care. The onset of generalized tonic–clonic
seizures is usually abrupt, although 20% to 30% of children may experience a
sensory or motor aura. If sitting or standing, the child falls to the ground. The face
becomes pale, the pupils dilate, the eyes deviate upward or to one side, and the
muscles contract. As the increased tone of the thoracic and abdominal muscles
forces air through the glottis, a grunt or cry may be heard. Incontinence of urine
or stool is common. After this brief tonic phase (10 to 30 seconds), clonic


movements occur. The child is unresponsive during the seizure and remains so
postictally for a variable period. After the seizure, there may be weakness or
paralysis of one or more areas of the body (Todd paralysis). In atonic, or akinetic,
seizures (drop attacks), there is abrupt loss of muscle tone and consciousness.
Myoclonic seizures are characterized by a sudden dropping of the head and
flexion of the arms (jackknifing); however, extensor posturing may also occur.
The episodes occur quickly and frequently, as often as several hundred times
daily.
TABLE 97.2
SEIZURE TYPES
Generalized

Partial (focal)

Absence (petit mal)
Typical
Atypical
Tonic–clonic (grand mal)
Clonic
Tonic
Myoclonic

Akinetic/atonic (drop attacks)

Simple (no impaired consciousness)
Motor
Sensory
Autonomic
Psychic
Complex (impaired consciousness)
Partial seizures becoming partially
generalized

Absence (petit mal) seizures are generalized seizures, marked by sudden and
brief loss of awareness, usually lasting 5 to 30 seconds. With typical absence
seizures, there is no loss of posture or tone and no postictal confusion. There may
be a minor motor component such as eyelid blinking.
The child with simple partial (focal) seizures has unimpaired consciousness.
Motor signs are most common in children, although sensory, autonomic, and
psychic manifestations are possible. The motor activity usually involves the
hands or face and spreads in a fixed pattern determined by the anatomic origin of
the nerve fibers that innervate the various muscle groups. Focal seizures may
become secondarily generalized, in which case there will be alteration of
consciousness. Complex partial seizures, also called psychomotor or temporal
lobe seizures, exhibit a diverse set of clinical features, including alterations of
perception, thought, and sensation. In children, they are usually marked by


repetitive and complex movements with impaired consciousness and postictal
drowsiness.
An important distinction is whether the seizure is associated with fever. Simple
febrile seizures are those that are single, brief (lasting less than 15 minutes), and

generalized. Approximately 20% of febrile seizures are complex, meaning they
are focal, prolonged (last for more than 15 minutes), or have multiple episodes
within 24 hours.
Triage and Initial Assessment
For an actively seizing child, initiate immediate resuscitative measures and
consider administration of antiepileptic agents, as discussed below. After seizures
have stopped, the first steps in the evaluation are a thorough history and a
physical examination, the results of which are helpful in determining the direction
of the search for a specific cause (see Table 72.1 and Fig. 72.1 ). Important
historical items to elicit include fever, trauma, underlying illnesses, current
medications, and possible toxic ingestions. A complete neurologic assessment to
evaluate for signs of increased intracranial pressure (ICP), focal deficits, or signs
of meningeal irritation is also essential.
Diagnostic Testing
In children older than 12 months with a typical simple febrile seizure and no signs
of meningitis, generally no further evaluation of the seizure is required. However,
lumbar puncture (LP) is indicated if meningitis is suspected on the basis of
physical findings. An LP should be considered in children younger than 12
months, in whom signs of meningitis may be subtle, such as irritability and poor
feeding; when the febrile seizure is complex; or if there has been pretreatment
with antibiotics. In addition, LP should be considered for children with prolonged
fever before the seizure, and for febrile children who do not return to neurologic
baseline quickly. Other laboratory tests discussed in the next paragraph have been
found to have little yield in the child with a typical febrile seizure and are
unnecessary. Appropriate diagnostic tests to determine the source of the fever are
determined by other features such as the intensity of fever, immunization status,
and the child’s age.
For the child who presents with a first-time, nonfebrile seizure, laboratory or
radiologic evaluation to search for a specific treatable cause of the seizure may be
indicated. There is little utility in extensive, routine workups; rather, ancillary test

selection should be guided by the results of the history and physical examination.
In young infants, children with prolonged seizures, and those with a suggestive


history or physical examination, determination of serum glucose, sodium, and
calcium levels are indicated. Other ancillary tests that may be indicated,
depending on the clinical picture, include serum magnesium, hepatic
transaminases, ammonia, serum or urine toxicology tests, electrocardiogram
(ECG), and neuroimaging of the brain. LP is rarely emergently necessary in the
afebrile child without meningeal signs or altered mental status, although it should
be considered in neonates even without fever.
In children with a known seizure disorder, subtherapeutic anticonvulsant levels
are the most common reason for breakthrough seizures. The name and dosage of
anticonvulsant medications used should be elicited, as well as the time of the last
dose given, any missed doses, the last change in dosage, and recent levels, if
known. Intercurrent illness may also play a role because the metabolism of some
medications is affected by systemic illness. Such children should have blood
drawn for measurement of anticonvulsant levels. Although many drugs have a
standard therapeutic range ( Table 97.3 ), individual patients may require levels
outside that range for adequate seizure control; conversely, dose-dependent toxic
effects may be observed in some children even at typically therapeutic levels.
Computed tomography (CT) (or magnetic resonance imaging [MRI], if
available) is indicated in the emergency evaluation of prolonged or focal seizures,
when focal deficits are present, when there is a history of trauma, when the child
has a ventriculoperitoneal shunt, or when there are associated signs of increased
ICP. For other children with a normal neurologic examination, MRI may be
useful in identifying structural anomalies and determining prognosis, but such
studies may be deferred to a follow-up visit. Cranial imaging is not indicated in
the evaluation of simple febrile seizures. EEG is also helpful in the evaluation of
children with nonfebrile seizures. EEG is rarely beneficial in acute management,

but children with nonfebrile seizures should be referred for outpatient testing.