First time non-febrile seizure

·         A healthy child older than 12 months can be safely discharged without emergent imaging when there is no concern for an underlying structural, traumatic, or infectious etiology that may require intervention.

·         Patients who are at higher risk for a focal finding include those:

o   With recurrent or persistent seizures

o   Who are from areas endemic for cysticercosis (ie, Mexico)

o   Who are immunocompromised

o   Have hypercoaguable states such as sickle cell disease

o   Have sustained trauma

o   Have VP shunts or other conditions which put them at higher risk for having elevated intracerebral pressure (ICP)

·         Neuroimaging is preferred in children under 12 months in the setting of first time seizure.

Imaging Modality

·         In the ED, CT or MRI can be obtained to evaluate for any of these findings.  

·         As an outpatient, non-emergent MRI is the indicated test.

Ancillary Tests

Other tests which may be indicated, as determined based on history and physical examination, include:

·         serum glucose

·         serum electrolytes

·         urine toxicology

·         lumbar puncture (rarely indicated)

In general, children with isolated first time seizures without any identifiable etiology are not started on anti-epileptic agents. Expeditious follow up with a specialist for outpatient MRI and EEG is indicated.

http://www.neurology.org/content/55/5/616.full.pdf

Linda Regan, MD FACEP

Associate Director, Emergency Medicine Residency

Johns Hopkins Medical Institutions