Pediatric emergency medicine trisk 2611 2611
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repetitive and complex movements with impaired consciousness and postictal
drowsiness.
An important distinction is whether the seizure is associated with fever. Simple
febrile seizures are those that are single, brief (lasting less than 15 minutes), and
generalized. Approximately 20% of febrile seizures are complex, meaning they
are focal, prolonged (last for more than 15 minutes), or have multiple episodes
within 24 hours.
Triage and Initial Assessment
For an actively seizing child, initiate immediate resuscitative measures and
consider administration of antiepileptic agents, as discussed below. After seizures
have stopped, the first steps in the evaluation are a thorough history and a
physical examination, the results of which are helpful in determining the direction
of the search for a specific cause (see Table 72.1 and Fig. 72.1 ). Important
historical items to elicit include fever, trauma, underlying illnesses, current
medications, and possible toxic ingestions. A complete neurologic assessment to
evaluate for signs of increased intracranial pressure (ICP), focal deficits, or signs
of meningeal irritation is also essential.
Diagnostic Testing
In children older than 12 months with a typical simple febrile seizure and no signs
of meningitis, generally no further evaluation of the seizure is required. However,
lumbar puncture (LP) is indicated if meningitis is suspected on the basis of
physical findings. An LP should be considered in children younger than 12
months, in whom signs of meningitis may be subtle, such as irritability and poor
feeding; when the febrile seizure is complex; or if there has been pretreatment
with antibiotics. In addition, LP should be considered for children with prolonged
fever before the seizure, and for febrile children who do not return to neurologic
baseline quickly. Other laboratory tests discussed in the next paragraph have been
found to have little yield in the child with a typical febrile seizure and are
unnecessary. Appropriate diagnostic tests to determine the source of the fever are
determined by other features such as the intensity of fever, immunization status,
and the child’s age.
For the child who presents with a first-time, nonfebrile seizure, laboratory or
radiologic evaluation to search for a specific treatable cause of the seizure may be
indicated. There is little utility in extensive, routine workups; rather, ancillary test
selection should be guided by the results of the history and physical examination.
In young infants, children with prolonged seizures, and those with a suggestive
