How should seizures be managed in the emergency department of a primary‑care hospital, and what are the differences in initial treatment, work‑up, and disposition between pediatric and adult patients?

Emergency Department Management of Seizures: Pediatric vs Adult Differences

Initial Stabilization (Universal)

Immediately assess airway, breathing, circulation and obtain bedside glucose in all patients—both pediatric and adult—before proceeding with further evaluation. 1

• Confirm return to baseline neurologic status, as this single determination guides all subsequent management decisions including laboratory testing, imaging, and disposition 1
• Administer IV dextrose or IM glucagon if glucose <60 mg/dL (3 mmol/L) 2

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Laboratory Testing: Key Pediatric-Adult Differences

Adults

Obtain only serum glucose and sodium in otherwise healthy adults who have returned to baseline—these are the only tests that consistently alter acute ED management. 3, 1

• Pregnancy test mandatory for all women of childbearing age 3, 1
• Additional metabolic panels (calcium, magnesium, phosphate) only when specific clinical findings suggest them (vomiting, diarrhea, dehydration, known renal disease, malignancy) 3, 1
• Consider toxicology screen in first-time seizures, though no prospective data support routine use 3

Pediatrics

Laboratory testing in children should be even more selective than adults—order tests only when clinical circumstances suggest metabolic derangements. 4

• Serum glucose and sodium remain the priority tests 1
• Pregnancy test if patient has reached menarche 1
• Toxicology screening should be considered across the entire pediatric age range if any question of drug exposure or substance abuse exists 1, 4
• Extensive laboratory panels in otherwise healthy children who have returned to baseline are very low yield and should be avoided 4

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Neuroimaging: Critical Age-Based Differences

Adults: Emergent CT Indications

Perform emergent non-contrast head CT in adults with any of the following high-risk features: 1

• Age >40 years
• Recent head trauma
• Focal seizure onset before generalization
• Fever or persistent headache
• Anticoagulation use
• History of malignancy or immunocompromised state
• Focal neurologic deficits
• Persistent altered mental status

CT abnormalities are found in 23-41% of first-time adult seizure presentations, with 22% having abnormal imaging despite normal neurologic examination. 3, 1

Pediatrics: More Conservative Imaging Approach

Emergent neuroimaging in children is indicated only if the patient exhibits a postictal focal deficit that does not quickly resolve or has not returned to baseline within several hours after the seizure. 1

• Simple febrile seizures (age 6 months-5 years) do not require neuroimaging 1
• Complex febrile seizures generally do not require imaging unless other neurological indications present 1
• Non-urgent MRI should be considered in children with significant cognitive/motor impairment of unknown etiology, unexplained neurologic abnormalities, or age <1 year 4

Both Populations

MRI is the preferred imaging modality for non-emergent evaluation in both adults and children, as it is more sensitive than CT for epileptogenic lesions. 1, 4

• Deferred outpatient MRI is acceptable for low-risk patients (returned to baseline, normal exam, reliable follow-up) 1

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Lumbar Puncture: Similar Indications Across Ages

Reserve lumbar puncture for patients with suspected meningitis or encephalitis—routine LP is not indicated for uncomplicated first-time seizures in either adults or children. 3, 1

Specific Indications (Both Populations):

• Fever with meningeal signs 1
• Immunocompromised status (after negative CT for mass effect) 3, 1
• Persistent altered mental status without alternative explanation 1

Critical caveat: In one pediatric case series of 503 children with meningitis, no case of occult bacterial meningitis manifested solely as a simple seizure 3

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EEG: Universal Recommendation with Timing Differences

EEG is mandatory as part of the neurodiagnostic evaluation for both adults and children with an apparent first unprovoked seizure. 1, 4

Emergent EEG Indications (Both Populations):

• Persistent altered consciousness after seizure to detect nonconvulsive status epilepticus 1
• Refractory status epilepticus 1

Routine EEG:

• Outpatient EEG is acceptable for uncomplicated first seizures in both populations 1, 4
• Abnormal EEG findings predict higher seizure recurrence risk and should influence treatment planning 1

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Disposition Decisions: Similar Criteria

Patients—both pediatric and adult—who have returned to their clinical baseline in the ED can be safely discharged without admission. 1, 4

Admission Criteria (Both Populations):

• Persistent abnormal neurologic findings 1
• Abnormal investigation results requiring inpatient management 1
• Has not returned to baseline 1
• Unreliable follow-up or social concerns 1

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Antiepileptic Drug Initiation: Adult-Focused Decision

Do not start an AED in the ED for provoked seizures or for a first unprovoked seizure when no evidence of prior brain disease exists. 1

• Consider initiating AED only when first unprovoked seizure occurs with remote symptomatic brain disease (prior stroke, TBI, tumor, chronic CNS disease >7 days ago) 1
• Starting AED after first seizure prolongs interval to next event but does not improve 5-year outcomes or mortality 1
• Number needed to treat to prevent one recurrence within 2 years is 14 patients 1

Pediatric-specific guidance on AED initiation is not addressed in the available guidelines—defer to outpatient neurology follow-up for children.

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Seizure Recurrence Risk

Adults:

• Overall 24-hour recurrence rate is 19%, decreasing to 9% when alcohol-related events and focal CT lesions are excluded 1
• Mean time to first recurrence is 121 minutes (median 90 minutes), with >85% occurring within 6 hours of ED presentation 1
• Nonalcoholic patients with new-onset seizures have lowest recurrence rate (9.4%) 1
• 30-50% experience recurrence within 5 years after first unprovoked seizure 1

Pediatrics:

• Specific recurrence data for pediatric populations not provided in available guidelines

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Status Epilepticus Management (Both Populations)

Benzodiazepines are first-line therapy for status epilepticus in both adults and children. 1

Pediatric-Specific Recommendations:

Non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) should be used as first-line therapy rather than rectal route. 2

Second-Line Agents (Adults):

• Phenytoin/fosphenytoin, valproate, or levetiracetam 1
• Valproate (30 mg/kg) is as effective as phenytoin with potentially fewer adverse effects like hypotension 1

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Common Pitfalls to Avoid

Adults:

• 28-48% of suspected first seizures have alternative diagnoses (syncope, nonepileptic seizures, panic attacks)—careful history is essential 1
• Alcohol withdrawal seizures should be a diagnosis of exclusion; search for symptomatic causes before labeling as withdrawal 1

Pediatrics:

• Do not routinely order extensive laboratory panels in otherwise healthy children who have returned to baseline 4
• Do not delay EEG—it is the single most important diagnostic test 4
• Do not perform neuroimaging for simple febrile seizures 1