What is the recommended evaluation and management for a pediatric patient presenting to the Emergency Department (ED) with a first-time seizure?

Evaluation of Pediatric Patients with First-Time Seizure in the Emergency Department

The recommended evaluation for a pediatric patient presenting to the Emergency Department with a first-time seizure should include essential laboratory tests (serum glucose, serum sodium), neuroimaging (MRI preferred over CT), and EEG, with specific management determined by the presence of fever, patient age, and seizure characteristics. 1

Initial Assessment

• Vital signs: Complete set including blood pressure measurement
• Neurological status: Assess for return to baseline mental status, focal deficits
• Seizure characteristics: Document type (generalized tonic-clonic most common at 71.2%), duration, and whether simple or complex 2
• Associated symptoms: Fever, headache, trauma, vomiting, neck stiffness
• Medical history: Prior seizures, developmental delays, recent illness, medications, family history

Laboratory Testing

Laboratory testing should be targeted rather than routine, based on clinical presentation:

• Essential tests for all patients:

  • Serum glucose (to rule out hypoglycemia)
  • Serum sodium (to identify hyponatremia)

• Additional tests based on clinical presentation:

  • Complete metabolic panel: For patients with altered mental status
  • CBC, blood cultures, lumbar puncture: For patients with fever and signs of meningitis
  • Toxicology screen: For patients with altered mental status or suspected substance exposure
  • CK levels: After generalized tonic-clonic seizures

Studies show that routine laboratory testing has low yield in children with first seizures who have returned to baseline, with only electrolyte abnormalities (particularly glucose and sodium) being commonly identified 1, 2.

Neuroimaging

Neuroimaging decisions should be guided by clinical factors:

• MRI is preferred over CT for detecting brain abnormalities (75% of abnormalities seen on MRI may be missed on initial CT) 1

• Indications for emergent neuroimaging:

  • Focal neurologic deficits
  • Persistent altered mental status
  • History of trauma
  • Signs of increased intracranial pressure
  • History of malignancy
  • Suspected neurocutaneous disorder

• Neuroimaging may be deferred in:

  • Simple febrile seizures
  • Primary generalized epilepsy with characteristic clinical features
  • Complete return to baseline with normal examination

Research indicates that abnormal brain images were found in 26% of patients who underwent imaging, with 75% of these patients having abnormal histories or neurological examinations 2.

Electroencephalography (EEG)

• EEG should be performed in all patients with first-time seizures 1
• Ideally performed within 24-48 hours of the seizure
• Helps differentiate seizure types and identify epilepsy syndromes
• May detect specific patterns that guide management

Management Based on Seizure Type

Febrile Seizures (most common etiology at 62.1%) 2

• Simple febrile seizures (generalized, <15 minutes, single in 24 hours):

  • Minimal workup needed
  • Focus on identifying source of fever
  • Discharge if well-appearing and >18 months old 3

• Complex febrile seizures (focal, >15 minutes, recurrent within 24 hours):

  • Consider more extensive evaluation
  • Admission recommended 3

Afebrile Seizures

• All children under 1 year: Admission recommended 3
• Children >1 year with normal exam and return to baseline:
  • Can consider discharge with close follow-up
  • Antiepileptic medications generally not indicated after first unprovoked seizure

Acute Management of Active Seizures

For patients still seizing upon arrival:

• First-line: Benzodiazepines (lorazepam 0.1 mg/kg IV, max 4 mg) 1, 4
• Equipment for airway management must be immediately available 4
• Status epilepticus: Additional 4 mg lorazepam may be administered if seizures continue after 10-15 minutes 4

Discharge Criteria

Patients can be discharged if they:

• Have returned to baseline mental status
• Had a single self-limited seizure with no recurrence
• Have normal or non-acute findings on neuroimaging (if performed)
• Have reliable follow-up available
• Have a responsible adult to observe them 1

Admission Criteria

Admission is recommended for:

• Children under 18 months with febrile seizures 3
• All children under 1 year with afebrile seizures 3
• Complex febrile seizures 3
• Persistent altered mental status
• Abnormal neuroimaging findings requiring intervention
• Suspected meningitis or encephalitis
• Status epilepticus
• Significant metabolic abnormalities

Follow-up Recommendations

• Neurology referral is essential for all patients with first-time unprovoked seizures 1
• Discharge instructions should include seizure precautions, safety measures, and triggers to avoid
• Parents should be educated about febrile seizure recurrence risk and home management

Common Pitfalls to Avoid

• Performing unnecessary routine laboratory tests and neuroimaging in well-appearing children with simple febrile seizures
• Failing to recognize signs of meningitis in febrile children
• Administering incorrect weight-based doses of anticonvulsants (studies show 36% of patients receive incorrect doses) 5
• Missing non-convulsive status epilepticus in patients with altered mental status
• Overlooking treatable causes such as hypoglycemia or hyponatremia

This evidence-based approach balances the need for thorough evaluation while avoiding unnecessary testing in low-risk patients, focusing on identifying those with potentially serious underlying conditions.