This document provides clinical guidance for all staff involved in the care and management of a child presenting to the Queensland Children’s Hospital Emergency Department (ED) after a first afebrile seizure. This guideline does not include management of the child who is actively seizing and does not apply to children with a known seizure disorder. Separate guidelines are available to address the management of a child who is actively seizing (Status Epilepticus Guideline)as well as those presenting with a febrile convulsion (Febrile Convulsion Guideline).
This guideline has been developed by senior ED clinicians and Paediatricians with input from relevant specialist teams at the Queensland Children’s Hospital.
Seizures are a common presenting complaint1and account for 1% of all paediatric emergency department visits2. Most seizures are brief and self-limiting with 8% of children having an unprovoked seizure by the age of 15 years3. Generalised seizures affect 4-10% of children with the highest incidence of convulsive seizures reported in children younger than 3 years of age2.
Seizures may be provoked or unprovoked. Provoked or acute symptomatic seizures are events occurring in close temporal relationship with an acute CNS insult (metabolic, toxic, environmental, structural, infectious or due to inflammation). Unprovoked seizures occur in the absence of a potentially responsible acute clinical condition2.
Provoked seizures include:
The first step in assessment is to ensure that the patient is no longer seizing.
Initial assessment should always ensure that the child is not actively seizing with rapid evaluation and support of the child's airway, breathing and circulation as required. The aim of assessment of a potential seizure event is first to determine whether the event was a seizure or a non-seizure event. Once a diagnosis of seizure has been made the focus then turns to determining whether the seizure is a manifestation of another pathology. Seizures resulting from another treatable illness are more common in children less than 6 months of age3. Consideration should always be given as to whether the seizure may be a manifestation of stroke (see Acute Arterial Ischaemic Stroke Management in Children Guideline) or non-accidental injury (NAI) with neuroimaging, further investigations and discussion with the child protection team if appropriate4.
| Non-Seizure Events | Conditions Presenting with Seizure |
|---|---|
|
|
Developmental delay or regression is a red flag for urgent general paediatric/neurology assessment.
There is no set of routine investigations for all patients. Investigation choice should be guided by features on history and examination and may require senior medical input. Potential investigations to be considered include:
| Investigation | Utility |
|---|---|
| Blood Sugar Level | A blood sugar level should be performed in all patients as soon as possible3. Seizures may be a manifestation of hypoglycaemia. |
| ECG |
Indicated if clinical picture suggestive of a cardiac cause for presenting event, particularly a syncopal event4,5. Key features to assess include:
|
| Consider Electrolytes | Useful in children less than 12 months of age or those where electrolyte disturbance is suspected based on the history and exam. Routine electrolyte testing has limited yield in children older than 12 months of age with a self-resolving seizure1. Indications for measurement:
|
| Consider Lumbar Puncture with CSF Analysis | Indicated if clinical picture suggestive of meningitis, encephalitis or subarachnoid haemorrhage is considered6. LP should only be performed once the child has returned to their baseline neurological status. |
| Consider Blood Drug Level Assay | Indicated if clinical picture suggestive of drug or toxin ingestion6. Specific assay will be guided by suspicion of toxin involved (see Toxicology Guideline) |
Neuroimaging may be used to assess for underlying structural abnormalities7. Up to one third of children presenting with a first afebrile seizure will have abnormalities on neuroimaging, however only some of patients will have abnormalities that are clinically significant and influence management5. High resolution MRI is the test of choice6,7 for investigating seizures and is superior to CT in demonstrating parenchymal brain abnormalities5. CT may be preferred in certain situations, particularly when urgent imaging is necessary to exclude neurosurgical emergencies (hydrocephalus, empyema, intra-cranial bleed) or the child is unstable7. Neurological emergencies require urgent MRI brain as per hospital pathway or Acute Arterial Ischaemic Stroke Management in Children Guideline. Children with a clinical picture and EEG findings consistent with (benign) focal epilepsies of childhood (previously Rolandic and Panayiotopoulos) do not necessarily require neuroimaging5.
Indications for urgent neuroimaging in the ED include:
Advice on the type of neuroimaging can be sought from radiology/neurology/neurosurgery.
Indications for outpatient neuroimaging as part of work-up:
Children presenting to QCH ED may be considered for a referral for an EEG if they present with a first afebrile seizure or a clinical picture necessitating an EEG. All of these cases should first be discussed with the on-call paediatrics team to decide if an EEG is indicated and appropriate follow-up of the result arranged (see management below). See EEG clinical prioritisation list.
EEG is not a useful screening test for epilepsy as a normal EEG can be seen in up to half of patients with epilepsy8. Similarly, EEG abnormalities can be seen in patients who do not have epilepsy and therefore do not confirm the diagnosis5,7. It can, however, yield important information prior to first paediatric appointment, including diagnosis of a specific epileptic syndrome, making a diagnosis of (benign) focal epilepsy of childhood (as these children may only have a single episode) and assessing the diagnostic and management applications of brief seizures (such as absences and myoclonic jerks)5,8. While an EEG is not routinely required in the investigation of a seizure it may be useful to help determine the seizure type and epilepsy syndrome7. The NICE guidelines recommend that an EEG be performed after the second seizure but can be considered after a first epileptic seizure following discussion with specialist7. Dr Panayiotopoulos clearly defined the advantages of an EEG after the first seizure, stating that the child and the family are entitled to a diagnosis, prognosis and management that is specific and precise, even though this may only be possible in a select-proportion of patients after the first seizure9.
For management of a child who is actively seizing please refer to the Status Epilepticus Guideline.
The main priority in the child presenting after a seizure is to ensure their protection and optimise safety during the post-ictal period1. Children should be placed in the recovery position and support provided for maintenance of airway and breathing if required3. Children should be monitored for further seizure activity and focal neurological signs as well as regular assessments made to ensure improvement in neurological status3. For disposition planning, please see Appendix 1: Disposition planning for patient with a First Afebrile Seizure flowchart.
Anti-epileptic treatment is not usually commenced after a first unprovoked seizure5. However, there are specific circumstances where commencement after first afebrile seizure may be appropriate. Initiation of anti-epileptic treatment from Emergency should only be by the general paediatric team, following review and with appropriate medication counselling. These patients are subsequently referred for outpatient follow-up to ensure appropriate monitoring of medication effectiveness, side effects and titration of doses.
Children who present with ongoing or have a recurrence of seizures should be managed in an appropriate area with early senior emergency staff input. Please see the Status Epilepticus Guideline for further details. Patients with airway compromise as a result of decreased level of consciousness following a seizure require management in a resuscitation area with staff trained in airway management.
Features on history and examination necessitating early senior emergency staff involvement include:
Children with an assessment suggestive of an unprovoked afebrile seizure who have returned to their baseline and have no other concerning features on assessment can be considered for discharge. It is important that all patients being discharged receive appropriate discharge education and have a plan for ongoing follow-up in place.
Any patient who has had a seizure is at risk of another seizure4. Parents should be educated on the importance of increased adult supervision of their child, particularly for activities where a seizure will place the child at increased harm.
Examples of ways to minimise harm include:
Parents and care givers should be educated on the recognition and management of a seizure7. Children should be laid on their side to prevent choking on saliva with pillows or cushions around their child to prevent injury from the hard floor or surrounding furniture. Parents should be advised not to prevent shaking during a seizure as well as from putting their fingers or other foreign objects in their child's mouth due to the risk of injury and airway obstruction. The duration of a seizure as well as the post-ictal period should be timed. Parents should be encouraged to attend first aid courses to assist with their knowledge on the management of a seizure or a post-ictal patient. Parents should also be empowered to call for emergency services assistance early4.
To help with further evaluation and management, parents should be encouraged to video further events if possible as well as keep a log of dates of events, associated symptoms and length of seizure. This is particularly important where diagnosis of the event is unclear or when specialist review is planned4.
A printable First aid for seizures handout is available and should be provided to parents on discharge.
It is recommended that children presenting with an afebrile seizure have urgent outpatient follow-up to ensure precise and early diagnosis as well as initiation of therapy if appropriate7. A diagnosis of epilepsy is usually made by a specialist rather than in the emergency setting7. Patients should be discussed with the on-call general paediatric team as part of referral for a category one outpatient review. The need for outpatient neuroimaging and EEG can be discussed at the time and appropriate referrals made if appropriate.
Indications for admission to a general paediatric team for further management and investigation include3