Pediatric emergency medicine trisk 1435 1435
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spine can be thoroughly examined. Examination of the chest, lungs, and abdomen
is performed in the usual fashion. The extremities are examined for the evidence
of trauma, especially as the result of falling during a seizure.
The neurologic examination may be limited by either ongoing seizure activity
or a postictal state and may consist solely of the pupillary examination, an
assessment of any asymmetric movements (focality), and best response to stimuli.
Any abnormal posturing (decerebrate or decorticate) should be noted and dealt
with immediately, with emergent imaging and possibly neurosurgical
intervention. During the postictal state, presence of a Todd paresis should be
recorded.
If there is a question of a possible ingestion, the examination is also directed at
uncovering a potential toxicologic syndrome (toxidrome) that may suggest a
specific class of drugs or toxins that are responsible for the seizure (see Chapter
102 Toxicologic Emergencies ). Important variables include temperature, heart
rate, blood pressure, pupil size, sweating, flushing, and cyanosis.
As the patient recovers from the seizure episode, periodic reassessment is
needed to assess for any underlying neurologic abnormalities.
DIAGNOSTIC APPROACH
Once it has been determined that a seizure may have taken place, the initial
diagnostic evaluation (Fig. 72.1 ) starts with the history and physical examination.
Laboratory, radiologic, and other neurodiagnostic testing (e.g., EEG) are other
tools that can be a part of the seizure evaluation.
Patients with obvious trauma who are seizing should be treated per advanced
trauma life support (ATLS) guidelines (see Chapter 7 A General Approach to the
Ill or Injured Child ), with close attention to possible intracranial injury (see
Chapter 113 Neurotrauma ). Often, patients with a known seizure disorder will
present to the ED actively seizing. Patients known or suspected to be taking
anticonvulsants should have drug levels evaluated. A subtherapeutic
anticonvulsant level is among the most common reasons for patients to present
with seizures. At times, a concurrent mild infectious process (URI, diarrhea) may
have an effect on both seizure threshold and/or anticonvulsant
absorption/metabolism.
Many different laboratory tests may reveal a cause for a seizure and, as a result,
suggest a potential treatment. A rapid glucose reagent strip test should be
performed with the initial blood sample. Hypoglycemia is a common problem
that can often precipitate seizure activity. If hypoglycemia is documented or a
rapid assessment is not available, treatment with 0.25 to 1 g/kg of dextrose is
