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


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

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. Additional seizure manifestations 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.

Associated clinical signs 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.


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 seizures is listed in Table 76-1.

Table 76-1

Suggested ED Evaluation of Pediatric Seizures

Status epilepticus is defined as seizure activity lasting >30 minutes or multiple seizures without a return to normal mental status between seizures. Five minutes have been suggested as an operational definition because seizures lasting longer than 5 minutes usually do not resolve without treatment. Status epilepticus is a medical emergency, and is more responsive to medications when treated early and aggressively.

Seizures must be distinguished from other events that masquerade as seizures in children such as syncope, ...

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