Seizure - First presentation

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff with the assessment and management of a first seizure. presentation.

Definition

A seizure is the physical and behavioural changes that occur after an episode of abnormal activity in the brain or part of the brain.
It is a symptom not a diagnosis.

Background

By the age of 16 years, approximately 1% of the population will have suffered a seizure without a fever.^1,2,3
Recurrence risk:^2,3
- 25% will have a second afebrile seizure in the next year
- 45% will have a second afebrile seizure in the next 14 years
  - 75% of those will have a third afebrile seizure
  - 88% of those are within two years.

Assessment

History

General history including:

fever
headache and/or photophobia
neurological state and behaviour prior to seizure
duration of seizure, focal features
recent trauma
poisons / drug ingestion
co-morbidities e.g. ventriculoperitoneal (VP) shunt
developmental history
determine if the child has had a vaccination in the past 14 days. If so, a WAVSS WA Vaccine Safety Surveillance: Adverse Reaction Reporting Form needs to be completed.

Examination

Systems examination including full neurological examination
Assess for meningism

Investigations

Glucose
UEC, Calcium, Magnesium, Phosphate
CT if clinically indicated (seek Emergency Department Senior Doctor advice)
ECG
EEG to be arranged by General Paediatric Team if appropriate when outpatient referral received
Metabolic screen if clinically indicated.

Differential diagnoses

Febrile convulsion
Meningoencephalitis
Breath holding
Syncope
Gastro-oesophageal reflux (GOR)
Arrhythmias
Stroke
Panic attack
Migraine
Psychosis
Pseudo seizures

Management

Most seizures will self-terminate within 5 minutes. Those that last longer are likely to require treatment to terminate.
If a seizure is still in progress on arrival to the Emergency Department, treatment should commence as per ED Guideline: Status epilepticus.

Admission criteria

Prolonged seizure > 15 minutes
GCS < 15 (1 hour post seizure)
Atypical febrile convulsion
Age < 1 year
> 1 seizure
Focal seizures
Signs of raised intracranial pressure (ICP)
Meningoencephalitis
Signs of aspiration
Non accidental injury (NAI)
High parental / carer anxiety

Discharge criteria

Parents should be warned that all children or adolescents who have had seizures should be supervised when bathing, swimming, riding a bicycle on the road, and should avoid tree climbing.
Parents should be advised of first aid measures and given parent information sheet - First Aid for Seizures.
Arrange referral to General Paediatric Clinic.

References

Hirtz D, Berg A, Bettis D, Camfield C, Camfield P et al; Practice Parameter: Treatment of the Child with a First Unprovoked Seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Quality Standards Subcommittee of the American Academy of Neurology, Practice Committee of the Child Neurology Society Neurology. 2003;60(2):166.
Arthur TM, deGrauw TJ, Johnson CS, Perkins SM, Kalnin A, et al; Seizure recurrence risk following a first seizure in neurologically normal children. Epilepsia. 2008; 49(11):1950.
Shinnar S, Berg AT, MoshéSL, Petix M, Maytal J, Kang H, Goldensohn ES, Hauser. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics. 1990;85(6):1076-85.

Endorsed by:	CPAC	Date:	May 2020
		Review date:	May 2023

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