Pediatric emergency medicine trisk 2612 2612
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history or physical examination, determination of serum glucose, sodium, and
calcium levels are indicated. Other ancillary tests that may be indicated,
depending on the clinical picture, include serum magnesium, hepatic
transaminases, ammonia, serum or urine toxicology tests, electrocardiogram
(ECG), and neuroimaging of the brain. LP is rarely emergently necessary in the
afebrile child without meningeal signs or altered mental status, although it should
be considered in neonates even without fever.
In children with a known seizure disorder, subtherapeutic anticonvulsant levels
are the most common reason for breakthrough seizures. The name and dosage of
anticonvulsant medications used should be elicited, as well as the time of the last
dose given, any missed doses, the last change in dosage, and recent levels, if
known. Intercurrent illness may also play a role because the metabolism of some
medications is affected by systemic illness. Such children should have blood
drawn for measurement of anticonvulsant levels. Although many drugs have a
standard therapeutic range ( Table 97.3 ), individual patients may require levels
outside that range for adequate seizure control; conversely, dose-dependent toxic
effects may be observed in some children even at typically therapeutic levels.
Computed tomography (CT) (or magnetic resonance imaging [MRI], if
available) is indicated in the emergency evaluation of prolonged or focal seizures,
when focal deficits are present, when there is a history of trauma, when the child
has a ventriculoperitoneal shunt, or when there are associated signs of increased
ICP. For other children with a normal neurologic examination, MRI may be
useful in identifying structural anomalies and determining prognosis, but such
studies may be deferred to a follow-up visit. Cranial imaging is not indicated in
the evaluation of simple febrile seizures. EEG is also helpful in the evaluation of
children with nonfebrile seizures. EEG is rarely beneficial in acute management,
but children with nonfebrile seizures should be referred for outpatient testing.
