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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 correct diagnosis.

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.

Types of Seizure

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 convulsivegeneralized 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 ...

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