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The causes and manifestations of seizure activity are numerous, ranging from benign to life threatening. Precipitants of seizures can include head injury, structural brain abnormalities, fever, CNS infection, hypoglycemia, electrolyte abnormalities, hypoxemia, toxin exposure, dysrhythmias, metabolic disorders, congenital infections, or neurocutaneous syndromes.

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The clinical features of seizure activity depend on the area of the brain affected and can range from classic tonic-clonic movements to very subtle behavioral changes; they may be generalized (with loss of consciousness) or partial (with focal motor or behavioral features). Rhythmic repetitive movement, incontinence of bowel or bladder, postictal state after a seizure, and tongue biting are strong clues to a seizure.

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Motor changes (tonic or clonic) may be focal or generalized, and seizures may present with atony (sudden loss of tone or “drop attack”) in some age groups. More subtle symptoms include staring spells (“absence”) or changes in mental status or behavior, which can be complex, such as automatisms (blinking, bicycling, or lip smacking in infants), vocalizations, or hallucinations.

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Signs may include alteration in autonomic dysfunction, such as mydriasis; diaphoresis; tachypnea or apnea; tachycardia; hypertension and salivation; and postictal somnolence. Transient focal deficits may represent Todd's paralysis following a seizure.

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The diagnosis of seizure disorder is based primarily on history and physical examination. Bedside glucose testing should be performed on all children who are seizing or postictal, but the clinical scenario should direct additional laboratory and imaging tests. Screening tests for electrolytes are not indicated in most cases of childhood seizures including simple febrile seizures or first time afebrile seizures, unless otherwise indicated by the specific history. The suggested ED evaluation of differing clinical scenarios presenting with seizure is listed in Table 76-1.

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Table 76-1 Suggested ED Evaluation of Pediatric Seizures

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