Pediatric emergency medicine trisk 1431 1431
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Psychogenic nonepileptic seizures (PNES) were formerly called
“pseudoseizures.” They are a movement disorder that resembles seizure activity,
but have no corresponding abnormal brain electrical activity. PNES include a
wide array of conditions ranging from conversion reaction to movement disorder
and even parasomnias. When the event is psychogenic in nature, the movements
can be quite startling, are typically bizarre and thrashing, and are often associated
with a great deal of vocalization. There is usually no biting, incontinence, or
injury associated with PNES. In contrast to seizures, PNES are rarely followed by
a postictal period or postictal headache, and patients often possess a clear mental
status after the event. PNES should also be suspected when the episodes are
almost always witnessed or heard and never during sleep, rather than occurring
randomly, and if the eyes are closed during the episodes (the eyes are closed in
less than 10% of actual seizures). In some cases, diagnosis may require long-term
video and electroencephalographic (EEG) monitoring. Further complicating the
issue is that PNES are most likely to occur in patients with an underlying seizure
disorder ( Table 72.2 ).
Breath-holding spells are common, affecting 4% to 5% of all children (see
Chapter 126 Behavioral and Psychiatric Emergencies ). They typically present
between the ages of 6 and 18 months and rarely persist past 5 years of age. The
two types of breath-holding spells—cyanotic and pallid—have common features,
including a period of apnea and an alteration in the state of consciousness.
Usually, some initiating event (e.g., pain, fear, agitation) triggers the episode. The
diagnosis is based on the clinical findings, and the prognosis is excellent.
A variety of movement disorders can also mimic seizures. Paroxysmal
choreoathetosis is often associated with a positive family history for seizures and
is exacerbated by intentional movement. Tic disorders can be manifested by
twitching, blinking, head shaking, or other repetitive motions. These are usually
suppressible and are not associated with any loss of consciousness. Shudder
attacks are whole-body tremors similar to essential tremor in adults. Benign
myoclonus of infancy can look like infantile spasms but is associated with a
completely normal EEG.
Sleep disorders, such as somnambulism, night terrors (preschool-aged
children), and narcolepsy (typically in adolescents) can often be diagnosed on the
basis of the history alone (see Chapter 126 Behavioral and Psychiatric
Emergencies ). Infants with gastroesophageal reflux may exhibit torticollis or
dystonic posturing (Sandifer syndrome). Atypical migraines and PNES are often
diagnosed after other causes are excluded.
INITIAL STABILIZATION
