What is the next step in management for a 3-year-old who presented to the emergency department (ED) with their first seizure and had normal initial test results, including computed tomography (CT) scan, complete blood count (CBC), basic metabolic panel (BMP), lactate and magnesium levels, and urinalysis (UA)?

Next Steps for a 3-Year-Old Following First Seizure with Normal ED Workup

The next step is to arrange outpatient EEG and MRI, with neurology follow-up, while ensuring the child has returned to baseline neurologic status before discharge home without starting antiepileptic medications. 1

Immediate ED Disposition

Discharge home is appropriate if the child has returned to clinical baseline with a normal neurologic examination. 1 The American College of Emergency Physicians states that emergency physicians need not admit patients with a first unprovoked seizure who have returned to their clinical baseline in the ED. 1

• Admission should be considered only if persistent abnormal neurologic examination results, abnormal investigation results, or the patient has not returned to baseline. 1
• The risk of early seizure recurrence is relatively low (9.4% in nonalcoholic patients), with 85% of recurrences occurring within 6 hours of the initial event. 1

Essential Outpatient Neuroimaging

MRI is the preferred imaging modality for pediatric first seizures when not in an emergent situation. 1 While the ED already performed CT (which was normal), MRI provides superior detail for identifying structural abnormalities that may not be visible on CT.

• The American College of Radiology recommends MRI as the preferred imaging modality for new-onset seizures in non-emergent situations. 1
• CT was appropriate in the ED to rule out emergent pathology (hemorrhage, acute stroke, mass effect), but MRI should follow as an outpatient study. 1, 2
• Deferred outpatient neuroimaging is acceptable for patients who have returned to baseline, have normal neurologic examination, and have reliable follow-up arrangements. 1

Electroencephalography (EEG)

EEG should be obtained as part of the neurodiagnostic evaluation. 1 The American Academy of Neurology recommends EEG as part of the evaluation of a child with an apparent first unprovoked seizure. 1

• EEG should ideally be performed during both wakefulness and sleep for optimal yield. 1
• Abnormal EEG findings predict increased risk of seizure recurrence and help guide treatment decisions. 1
• The EEG helps differentiate seizure types and may identify epileptiform abnormalities that influence prognosis. 3, 4

Antiepileptic Drug Considerations

Do not start antiepileptic medications at this time. 1 The American College of Emergency Physicians recommends that antiepileptic drug treatment reduces 1-2 year recurrence risk but does not affect long-term recurrence rates or remission rates. 1

• Starting treatment for a single seizure exposes patients to medication adverse effects without proven mortality or morbidity benefit. 1
• The decision to initiate antiepileptic therapy should be deferred to the neurologist after completion of EEG and MRI, based on assessed risk for recurrence. 1, 5
• Treatment decisions depend on EEG findings, imaging results, seizure type, and family preferences regarding recurrence risk versus medication side effects. 6

Neurology Referral

Arrange outpatient neurology follow-up within 1-2 weeks. 1 The neurologist will:

• Review EEG and MRI results
• Assess seizure recurrence risk based on clinical features, EEG abnormalities, and imaging findings
• Make decisions regarding antiepileptic drug initiation
• Provide counseling about seizure precautions and activity restrictions

Risk Stratification for Recurrence

The risk of recurrence at 1 year ranges from 14-36%, with higher risk in those with: 1

• Abnormal neurological examination
• Abnormal EEG findings
• Remote symptomatic seizures
• Todd's paralysis (postictal focal deficit)

Critical Safety Counseling

Provide seizure precautions to parents before discharge:

• Supervise bathing and swimming closely
• Avoid heights and dangerous machinery
• Discuss activity restrictions with the neurologist
• Return immediately for any seizure recurrence, persistent altered mental status, or focal neurologic deficits 1

Common Pitfalls to Avoid

• Do not skip outpatient MRI just because CT was normal - MRI is superior for detecting subtle structural abnormalities, cortical dysplasia, and other epileptogenic lesions. 1, 2
• Do not start antiepileptic drugs empirically - this decision requires specialist input and consideration of individual risk factors. 1
• Do not assume reliable follow-up - actively schedule neurology appointment and imaging before discharge to ensure completion. 1
• Do not miss immunocompromised status - if present, lumbar puncture should be performed even with normal CT. 1, 7