Pediatric emergency medicine trisk 2607 2607
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in children between the ages of 6 months and 6 years. The exact cause of febrile
seizures remains elusive. Elevated body temperature lowers the seizure threshold,
and the immature brain appears to have a particular susceptibility to seizures in
response to fever. Individual predisposition plays an important role.
During a seizure, cerebral blood flow, oxygen and glucose consumption, and
carbon dioxide and lactic acid production increase dramatically. If the patient
remains well ventilated, the increase in cerebral blood flow is sufficient to meet
the increased metabolic requirements of the brain. Brief seizures rarely produce
lasting deleterious effects on the brain; however, prolonged and serial seizures,
especially SE, may be associated with permanent neuronal injury.
Clinical Considerations
Clinical Recognition
When the physician is examining a child with an acute paroxysmal event, the first
step is to distinguish seizures from other nonepileptic phenomena. If the event is
indeed a seizure, it may be classified according to type. Finally, a specific
causative factor should be sought. The extent of the emergency evaluation is
determined by the clinical scenario; some of the diagnostic assessment may be
deferred. Of course, when a child is actively seizing, the first priority is to provide
necessary resuscitation measures and control the seizures (see Chapter 72
Seizures and the following sections).
Paroxysmal events other than seizures that involve changes in consciousness or
motor activity are common during childhood and may mimic epilepsy ( Tables
67.1 and 97.1 ). Breath-holding spells occur in children 6 months to 4 years of
age. Breath-holding spells take two forms: cyanotic and pallid. In the cyanotic
form, the infant begins crying vigorously, often in response to an inciting event,
then holds his or her breath and becomes cyanotic. After approximately 30 to 60
seconds, the child becomes rigid. As the spell ends, the child becomes limp and
may have a transient loss of consciousness and twitching or jerking of the
extremities, but the child quickly returns to full alertness. A pallid breath-holding
spell may follow a seemingly insignificant trauma. The child may start to cry, but
then turns pale and collapses. There is a brief period of apnea and limpness,
followed by rapid recovery. In both types of breath-holding spells, the typical
history and lack of postictal drowsiness help determine the diagnosis. Breathholding spells may be recurrent but disappear spontaneously before school age.
Syncope is a brief, sudden loss of consciousness and muscle tone. There are
numerous causes of syncope, many of which can be detected on the basis of
historical information, physical examination, and simple diagnostic tests (see
