Pediatric emergency medicine trisk 1439 1439
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resonance imaging (MRI) study if the patient’s condition allows. The following
situations should be considered emergent:
(i) a patient who has signs or symptoms of elevated ICP,
(ii) a patient who has a persistent focal neurologic deficit (Todd paresis vs. stroke),
and in selected patients with a focal seizure or,
(iii) a patient who has seizures in the setting of head trauma,
(iv) a patient who has persistent seizure activity or status epilepticus, or
(v) a patient who appears toxic.
Until C-spine injury is ruled out, it is important to maintain C-spine
immobilization when head trauma is a concern.
Patients with transient generalized seizures in whom a cause of the seizure
activity is identified probably do not require any further head imaging studies.
Patients with transient generalized seizures in whom no cause is identified and
who appear clinically well can have their head imaging performed on a
nonemergent basis in coordination with a pediatric neurologist.
In the past, because of easier availability and lack of a need for sedation for
most patients, CT scans were most often the study of choice in the ED for a
patient who presented with a seizure. However, given the heightened awareness
of the risks of ionizing radiation associated with CT scans, patients who do not
require emergent imaging may have an MRI study instead. An MRI study also
has several other advantages; MRI is better at identifying underlying white matter
abnormalities, disorders of brain architecture, lesions of the neurocutaneous
syndromes, lesions in the posterior fossa and the brainstem, and small lesions.
EEG is an important diagnostic tool in the evaluation of seizure types, response
to treatment, and prognosis. A limited EEG screen in the acute setting can rule
out subclinical or nonconvulsive SE and help with differentiating seizures from
some cases of psychogenic nonepileptic seizures or PNES (formerly known as
pseudoseizures). When there is uncertainty regarding ongoing seizure activity, an
urgent electroencephalogram (EEG) should be obtained. In the emergency
department, this can be a limited study, with application of only a few electrodes
to determine if the background is consistent with a normal awake individual (i.e.,
psychogenic nonepileptic seizure) or the diffusely slow and depressed
background of SE. Over recent years, various products and protocols have
emerged for quick lead placement (e.g., helmets, etc.) among actively seizing
patients.
EMERGENCY TREATMENT OF AN ACTIVE SEIZURE
