Seizures and epilepsy are common, serious neurologic diseases in children and adolescents.^1,2 Convulsions can be a manifestation of epilepsy or occur secondary to a complication of a systemic or central nervous system disorder. The emergency physician is usually the first provider to evaluate and stabilize children with suspected seizures. Here, we will review recent literature and share our personal experience in the approach to a seizing child in the emergency department.

Epilepsy is defined as the predisposition to generate seizures.^3,4 While generalized or focal shaking in a child readily raises a concern for seizure in caregivers and doctors alike, subtle manifestations, such as brief episodes of lip smacking in temporal lobe epilepsy or head bobbing in infantile spasms, can be challenging to correctly detect as signs of a serious neurologic disorder.

As with any other patient presenting to the emergency department, assessment of seizing children starts with determining stability and urgently addressing the ABCs. Careful attention should be given to the possibility of continuous seizure activity even if no apparent convulsions are seen. It’s helpful to consider the possibility that seizures were provoked so that their causes can be diagnosed and addressed.³ Table 1 enumerates causes of provoked seizures in patients without epilepsy.

(click for larger image) Table 1: Select Causes of Provoked Seizures⁸

Published guidelines on imaging in children with new-onset seizures note that in only approximately 2 to 4 percent of cases, the results altered immediate medical management.⁵ While MRI is the most accurate diagnostic modality in pediatric patients, for unstable patients in whom space-occupying lesions need to be excluded, a noncontrast CT scan of brain is the modality of choice as it is rapid, is readily available, and generally does not require sedation.^5,6 It is unusual to find an acute abnormality on imaging of a normally developed child (not an infant) with a completely normal neurological examination after a brief, nonlocalizing seizure.⁵ In these patients, imaging can be done on an outpatient basis as necessary. The same can be said for laboratory testing.

It is important to note that there are few studies prospectively evaluating timing of imaging in children with new-onset epilepsy. Some high- and low-risk characteristics are based on electroencephalogram (EEG) results. Most guidelines also exclude neonatal seizures.⁵ A seizure in a neonate almost always requires expeditious imaging and an EEG.6 An otherwise healthy and developmentally normal child older than 24 months after a brief first-time generalized seizure who quickly returns to normal can be discharged without medications with follow-up by pediatric neurology.^3,4,7,8 All of these patients will ultimately need an EEG, and most will require an MRI of the head.^5,6