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monitoring, as these medications can quiet clinical seizures despite ongoing
electrical seizures.
Clinical Considerations
Clinical Recognition. Clinical seizures can be focal clonic, multifocal or
migratory clonic, tonic, myoclonic, or subtle. The most common is the subtle
seizure, often presenting with repetitive tongue or lip-smacking movements, eye
deviations, or unusual bicycling or peddling movements. These movements may
be associated with autonomic dysfunction, such as changes in heart rate, blood
pressure, or oxygenation. The converse, autonomic disturbances such as apnea or
bradycardia without associated movement anomalies rarely reflect seizure
activity.
Triage Considerations. Neonates with suspected seizures should be triaged
urgently as prolonged seizures can cause permanent brain injury or progress to
systemic cardiorespiratory compromise.
Clinical Assessment. Often, parents will present to the ED with videos of
repetitive behaviors believed to be seizures. These videos can be very helpful.
Common causes of seizures are summarized in Table 96.4 . Detailed history can
suggest recent asphyxial events or trauma. Prenatal history can identify the
neonate at risk for withdrawal syndromes, and serum or urine toxicology screens
can identify acute intoxication. STAT bedside glucose and sodium testing should
be performed. Serum evaluation should include glucose and electrolytes
(including magnesium, calcium, and phosphorus). Ammonia, lactate, and
pyruvate can identify metabolic derangements as well as suggest certain IEM.
Serum blood gas evaluation may identify recent hypoxic–ischemic injury.
Cultures and viral testing of the blood, urine, and CSF can identify infection.
CNS imaging may include head US, CT, or MRI. Head US can be done through
the anterior fontanelle, and can help identify ventriculomegaly or intraventricular
hemorrhage, but could also suggest cerebral edema when the lateral ventricles are
small. Head CT is the test of choice when there is a concern for trauma or
cerebrovascular lesions. This does expose the neonate to radiation and so should
only be used when there is high suspicion of these lesions. Brain MRI can

identify CNS malformations, abscesses or empyemas (with the use of
gadolinium), asphyxial events (particularly with the use of diffusion-weighted
sequences), certain metabolic derangements and IEM (with magnetic resonance