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  • For febrile patients, the etiology of the fever should be investigated if it has not been determined on physical examination. A lumbar puncture is performed in any patient suspected of having a central nervous system infection.
  • Neuroimaging should be reserved for those with a postictal focal deficit (Todd's paralysis) that does not quickly resolve: a child whose level of consciousness remains depressed or who has not returned to baseline mental status within several hours.
  • A nonemergent magnetic resonance imaging (MRI) (several days later) should be considered in a child with an afebrile focal seizure that does not generalize: one with unexplained abnormalities on neurologic examination, unexplained cognitive or motor impairment, children younger than 1 year, and those who have had an electroencephalogram (EEG) that does not demonstrate a benign partial epilepsy or primary generalized epilepsy.
  • The MRI is preferable to a computed tomography (CT) scan in most cases as it can better demonstrate small tumors, vascular malformations, atrophy, infarction, and cortical dysplasia. If trauma is suspected, a CT scan is preferred so that an acute hemorrhage can be detected, but MRI is preferred for brain damage and old hemorrhage detection.
  • Any child who experiences a first focal seizure or who has an abnormal neurologic examination should be considered for hospital admission, with neurologic consultation. If the child has a first focal seizure, a nonfocal neurologic examination, and a negative emergency department (ED) workup and is stable, further workup can be performed on an outpatient basis in consultation with the child's primary physician, neurologist, and the parents or caretakers.
  • Neonatal seizures are commonly related to perinatal asphyxia, intracranial hemorrhage, central nervous system infections, cerebral infraction, metabolic abnormalities, especially hypoglycemia and hypocalcemia, and congenital abnormalities of the brain. Less commonly, seizures are related to inherited metabolic abnormalities, including urea cycle defects and abnormalities in amino acid metabolism.
  • For patients in whom an inherited metabolic defect is considered, serum ammonia is measured, as are serum and urine amino acids. Some defects are associated with a metabolic acidosis; therefore, arterial blood gas and, if possible, serum lactate are indicated.
  • Phenobarbital (20 mg/kg intravenously) is the drug of choice for neonatal seizures, with phenytoin (20 mg/kg) the second choice. In refractory seizures, pyridoxine (100 mg intravenously) is indicated, to treat for potential pyridoxine-dependent seizures.
  • For the first simple febrile seizure, there are no required laboratory studies other than a bedside glucose determination.
  • Benzodiazepines are usually effective treatment of actively seizing patients but are not useful for long-term seizure control. The administration of a long-acting antiseizure medication is indicated after seizures are controlled with benzodiazepines.


A seizure results from the abnormal, excessive, paroxysmal electrical discharge of neurons within the brain, primarily within the cerebral cortex.1 These discharges occur in various locations and may spread in different directions and at different speeds, resulting in several types of seizures, each with its own clinical manifestation.2 Epilepsy is defined as seizures that occur over a period of time without an obvious ...

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