Unusual movements and changes in behavior in children often lead
to an ED visit. Although seizures account for many of these events,
as many as 30% or more of paroxysmal events may be misdiagnosed
as seizures.1 Most seizure activity stops before
the child is seen in an ED. Therefore, history is key to make the
There are many different causes of pediatric seizures. The goal
is to identify and treat the underlying cause. Fortunately, most
pediatric seizures stop without intervention prior to medical assessment.
Some seizures require emergency management and extensive evaluation
(e.g., neonatal seizures). However, other seizures are very common
and benign and need very little evaluation (e.g., febrile seizures).
In this chapter, the different types of pediatric seizures, their
recognition, and their management are outlined.
The incidence of new-onset pediatric seizure in the U.S. is roughly 120,000
cases per year and is highest in children <2 years and in certain high-risk
groups.2 Febrile seizure is the most common type
of pediatric seizure, affecting 2% to 5% of children
between 6 months and 5 years of age.3 Epilepsy
is diagnosed when a patient has one or more unprovoked seizures.4,5 Roughly
326,000 children <15 years have epilepsy, and 1% of the
population can be expected to have epilepsy by the age of 20.2 The
incidence of status epilepticus in developed countries is between
17 and 23 cases per 100,000 and is higher for younger children.6
A seizure is a condition of paroxysmal involuntary motor activity
and/or changes in behavior caused by synchronous firing
of a group of neurons in the brain. The release of glutamate from
a firing neuron activates N-methyl-d-aspartic acid
receptors that subsequently initiate and propagate seizure activity.7 Seizures
are inhibited by γ-aminobutyric-acid (GABA), and
failure of this inhibition facilitates seizure spread.7 A
seizure’s electrical activity can be captured in an electroencephalogram (EEG).
Sometimes, however, seizure activity is not visible in an EEG, and the
diagnosis of epilepsy is made clinically.
There are many different seizure types. One primary distinction
is whether the seizure is generalized or partial, although a seizure
starting as partial can become generalized and vice versa. A clinical
description is important but sometimes not sufficient to categorize
a seizure, and an EEG or imaging study may be needed to determine
the seizure type with more certainty.
In a convulsive generalized seizure, both hemispheres
of the brain are involved and rhythmic motor stiffening and/or
shaking affects both sides of the body. A nonconvulsive generalized
seizure also involves both hemispheres of the brain but manifests
no motor activity—seizure activity is recognizable only
on EEG. In one study, nonconvulsive status epilepticus appeared
in 51 of 117 critically ill patients, with 75% of these patients
showing no clinical evidence of seizure activity.8
During both convulsive and nonconvulsive generalized seizures,
the patient loses consciousness and a postictal period follows.
Other generalized seizures include absence, atonic, and myoclonic seizures.
An absence seizure manifests as ...