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Unprovoked Seizure in Children
Aka: Unprovoked Seizure in Children, Pediatric Afebrile Seizure, First Time Seizure in Children
- See Also
- Single Seizure Evaluation
- Febrile Seizure
- Seizure Disorder
- Status Epilepticus
- Newborn Seizure
- Infantile Spasms
- Pediatric Spells
- Epilepsy in Pregnancy
- Epilepsy in Women
- Epilepsy in the Elderly
- Psychogenic Nonepileptic Seizure
- Precautions
- Evaluation described here is for unprovoked first-time Seizure
- See Seizure Disorder for full general evaluation
- Diagnosis: Seizure
- See Seizure Disorder
- See Single Seizure Evaluation
- Recurrent Seizure activity
- Seizures appear similar each time they recur
- Awareness
- Decreased awareness occurs with most Seizure types
- Distraction from Seizure activity by external events suggests a Seizure mimic
- Attempt to interact with child during Seizure-like activity in ways that they would ignore
- Motor activity
- Record the movements that occur with each episode (capture on video if possible)
- Incontinence and Tongue biting are not uniformly present in Seizures
- Often occur in Generalized Seizures, but not with Focal Seizures
- Differential Diagnosis
- Benign Seizure Mimics (esp. young children)
- See Seizure Differential Diagnosis
- Breath Holding Spells
- Motor Tic
- Child can often voluntarily suppress Motor Tics (contrast with Seizures)
- Atypical presentations or prolonged postictal period
- Closed Head Injury
- CNS Infection
- Electrolyte disturbance
- Inborn Errors of Metabolism
- Labs
- See Single Seizure Evaluation
- Fingerstick Glucose (all patients)
- Diagnostics
- Lumbar Puncture Indications
- Indicated in age <6 months (exam unreliable to exclude CNS Infection)
- Consider in age 6 to 12 months
- Perform if specifically indicated for age >12 months (similar indications for any age)
- Example: Altered Mental Status with fever (Meningitis or Encephalitis)
- Electroencephalogram (EEG)
- Only emergently indicated in suspected Status Epilepticus, or frequent, recurrent Seizures
- Defer to outpatient evaluation in most other cases
- EEG is typically delayed for 1-2 weeks after last Seizure (to allow non-specific slowing to clear)
- Imaging
- MRI Brain
- Evaluate for CNS mass
- Defer for oupatient imaging in a well-appearing child with normal Neurologic Exam
- CT Head
- MRI is preferred (CT is lower yield for CNS Lesions, MRI avoids radiation exposure)
- Emergent CT Head indications
- See Head Injury CT Indications in Children (PECARN)
- Consider in Non-accidental Trauma
- Consider for concerns of Increased Intracranial Pressure
- Management
- See Status Epilepticus
- See Single Seizure Evaluation
- See Seizure Disorder
- See Febrile Seizure
- Pediatric neurology referral
- Disposition
- Evaluation with imaging and EEG can often be deferred to outpatient evaluation
- However, admit all patients who have not returned to baseline following Seizure activity
- Discharge Instructions
- See Seizure Disorder
- Avoid swimming pools unless under very close 1:1 observation
- Wear helmets for activities at risk of Head Injury (e.g. biking)
- Showers are preferred over baths
- If baths are taken, they should be supervised continuously
- Seizure Prophylaxis
- Not recommended for single Seizure
- Recommended to start if more than one Seizure has occurred
- Rescue medication may be considered for discharge medication
- Parent may administer if Seizure lasts >5 minutes (and call 911)
- Options include Intranasal Midazolam and rectal Diazepam
- Prognosis
- See Single Seizure Evaluation
- Seizure risk recurrence in children
- After single first Seizure: 40-45%
- After second Seizure: 80%
- References
- Woods, Martin, Mason in Swadron (2022) EM:Rap 22(1): 6-8