New onset seizures without fever (6mo-18 years)



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New onset seizures without fever (6mo-18 years)

Fever > 38C (100.4F)

Has the seizure resolved?

Seizure precautions

Requires emergent neuroimaging?

Concern for toxic ingestion?

Meets discharge criteria?

Off pathway, treat appropriately

MRI preferred, but CT if not available

MRI Brain WO Contrast
CT Head WO Contrast

Neurology or general pediatrics consult

Treat appropriately for ingestion type. If unknown, but suspected consider broad screening of toxic metabolites.

Alcohol Volatile Screen, Serum
Urine Toxicology, Urine
Acetaminophen, Serum
Salicylate Level, Serum

Avoid using flumazenil in patients with suspicion of seizure as it may potential refractory seizure activity.

Symptoms & signs to consider neuroimaging

  • Focal component of seizures
  • Focal neurologic finding on exam
  • Concern for increased intracranial pressure
  • History of trauma precipitating seizure
  • Asymmetric EEG

Inclusion Criteria
  • History or direct observation consistant with a seizure
  • First seizure (excluding previous simple febrile seizures)
Exclusion Criteria
  • Complex past medical history (neurologic, metabolic, genetic or other)
  • VP shunt or intercrainal hardware
  • Immunocompromised or oncologic history
  • Previous afebrile seizure
  • History of coagulopathy or disease process predisposing to coagulopathy
  • Anticoagulant or coagulopathic medications
  • Epileptic/infantile spasms

Cardiac arrhythmias and syncope are often confused with epileptic activity. Consider ECG in any patient with non-classical signs for seizure.

Obvious source of seizure?

  • Discharge
  • Outpatient MRI & EEG (if not done)
  • Pediatric Neurology referral

Discharge criteria

  • Return to baseline mental status
  • Single seizure
  • Reassuring vital signs
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 1-3 days
  • Patient/Caregivers comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Symptoms associated with epileptic events

  • Cyanosis
  • Stereotyped presentation
  • Rarely precipitated by specific environmental, psychological, or physiological events
  • Occurs at random times of day or night
  • Post-ictal period




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