First afebrile seizure – Emergency management in children

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to the Queensland Children’s Hospital Emergency Department (ED) after a first afebrile seizure. This guideline does not include management of the child who is actively seizing and does not apply to children with a known seizure disorder. Separate guidelines are available to address the management of a child who is actively seizing (Status Epilepticus Guideline)as well as those presenting with a febrile convulsion (Febrile Convulsion Guideline).

This guideline has been developed by senior ED clinicians and Paediatricians with input from relevant specialist teams at the Queensland Children’s Hospital.

Introduction

Seizures are a common presenting complaint¹and account for 1% of all paediatric emergency department visits². Most seizures are brief and self-limiting with 8% of children having an unprovoked seizure by the age of 15 years³. Generalised seizures affect 4-10% of children with the highest incidence of convulsive seizures reported in children younger than 3 years of age².

Seizures may be provoked or unprovoked. Provoked or acute symptomatic seizures are events occurring in close temporal relationship with an acute CNS insult (metabolic, toxic, environmental, structural, infectious or due to inflammation). Unprovoked seizures occur in the absence of a potentially responsible acute clinical condition².

Provoked seizures include:

• Febrile seizure: generalised seizure in a previously healthy child aged between 6 month and 6 years of age during a febrile illness in the absence of a defined CNS infection²
• Benign convulsion associated with gastroenteritis: convulsive seizure occurring in a previously neurologically healthy child aged between 2 months and 6 years of age during a afebrile episode of gastroenteritis without clinical signs of dehydration and/or electrolyte imbalance²
• Acute symptomatic seizure: convulsive seizure occurring in a previously neurologically healthy child within 1 week of an identified acute neurological or systemic insult²
• Remote symptomatic seizure: convulsive seizure in a child with a previously known CNS abnormality occurring more than 1 week after an identified acute neurological or systemic insult². This group are also more likely to have recurrence of seizure.

Assessment

Initial assessment should always ensure that the child is not actively seizing with rapid evaluation and support of the child's airway, breathing and circulation as required. The aim of assessment of a potential seizure event is first to determine whether the event was a seizure or a non-seizure event. Once a diagnosis of seizure has been made the focus then turns to determining whether the seizure is a manifestation of another pathology. Seizures resulting from another treatable illness are more common in children less than 6 months of age³. Consideration should always be given as to whether the seizure may be a manifestation of stroke (see Acute Arterial Ischaemic Stroke Management in Children Guideline) or non-accidental injury (NAI) with neuroimaging, further investigations and discussion with the child protection team if appropriate⁴.

History

• Description of presenting event (document features accurately as described by witness)
  • Child's level of awareness
  • Focal signs or symptoms
  • Duration of seizure and any post-ictal period
  • Tonic-clonic movements - not diagnostic of a seizure as may occur as part of a tonic-clonic seizure or following vasovagal syncope
• Occurrences before, during and after the event
  • Pallor and sweating are typically observed immediately prior or during a vasovagal or syncopal event
  • Tongue biting - highly suggestive of a seizure
  • Presence of an aura, any subtle features described
  • Todd's paresis post seizure or other persisting focal neurological signs
  • Time until return to neurological baseline
    • Presence of a post-ictal period is highly suggestive of a seizure
    • Lack of a post-ictal period may suggest a non-seizure event unless the seizure is focal and brief or more characteristic of an absence seizure.
  • Incontinence during episode may be seen with a seizure as well as other non-seizure events
  • Increase in heart rate and blood pressure as well as pupillary dilation may be noted during a seizure if occurred in a monitored setting
• Circumstances around which the event occurred
  • Breath-holding spells may be triggered by pain, anger or frustration
  • Vasovagal episodes may occur after prolonged standing or associated with pain or fear
  • Seizure occurring immediately post a head injury or trauma
  • Occurrence during sleep or on waking is suggestive of a seizure
  • Occurrence after a sudden surprise or on maximal exertion - suggestive of an underlying cardiac pathology
• History of neurological disorders
  • Structural brain abnormality
  • Presence of a VP shunt
  • Previous intracranial haemorrhage
  • Previous infection, tumour, stroke
• History of coagulopathy or anti-coagulant medication - seizure may be a manifestation of intracranial haemorrhage
• History of renal failure or hypertension - seizure may be a manifestation of hypertensive encephalopathy
• History of endocrinopathy - seizure may be a manifestation of electrolyte disturbance
• History of malignancy - seizure may be the result of intracranial metastases or a complication of chemotherapeutic medications
• Recent medication changes
• Family history of seizures
• Family history of cardiac disorders including arrhythmia, pacemaker or sudden death in a family member < 40 years
• Previous history suggestive of absence seizures or myoclonic jerks
• Developmental history - structural brain abnormalities more common in children with neurological developmental delay,

Examination

• Neurological examination - intracranial or infectious causes of seizure suggested by:
  • Focal neurological features
  • Signs of raised intracranial pressure
  • Meningism
• Cardiovascular examination
• Skin exam in infants (including wood lamp, consider TSC)
• Features of a toxidrome - may be suggestive of a drug or toxin overdose (see Toxicology guideline)
• Signs of trauma - trauma may have precipitated seizure or may be the result of the seizure
• Developmental assessment
• Signs suggestive of NAI

Investigations

There is no set of routine investigations for all patients. Investigation choice should be guided by features on history and examination and may require senior medical input. Potential investigations to be considered include:

Neuroimaging

Neuroimaging may be used to assess for underlying structural abnormalities⁷. Up to one third of children presenting with a first afebrile seizure will have abnormalities on neuroimaging, however only some of patients will have abnormalities that are clinically significant and influence management⁵. High resolution MRI is the test of choice^6,7 for investigating seizures and is superior to CT in demonstrating parenchymal brain abnormalities⁵. CT may be preferred in certain situations, particularly when urgent imaging is necessary to exclude neurosurgical emergencies (hydrocephalus, empyema, intra-cranial bleed) or the child is unstable⁷. Neurological emergencies require urgent MRI brain as per hospital pathway or Acute Arterial Ischaemic Stroke Management in Children Guideline. Children with a clinical picture and EEG findings consistent with (benign) focal epilepsies of childhood (previously Rolandic and Panayiotopoulos) do not necessarily require neuroimaging⁵.

Indications for urgent neuroimaging in the ED include:

• Persistent altered level of consciousness without return to neurological baseline once the post-ictal phase and effects of medications have passed^1,3,5
• New focal neurological signs or symptoms including those concerning for stroke¹
• Suspicion on history and examination for an intracranial haemorrhage^1,4 or a history of previous intracranial bleed
• Patients who require a third-line anti-seizure medication to terminate the seizure²
• Children <6 months of age³
• Clinical findings suggestive of increased intracranial pressure³
• History of recent head trauma⁵
• History of persistent headache⁵
• Anti-coagulant use⁵ or known coagulopathy

Advice on the type of neuroimaging can be sought from radiology/neurology/neurosurgery.

Indications for outpatient neuroimaging as part of work-up:

• Patients with new onset unprovoked seizures before the age of 2 years⁷
• Suggestion of focal seizure on history, examination or EEG^3,7

EEG

Children presenting to QCH ED may be considered for a referral for an EEG if they present with a first afebrile seizure or a clinical picture necessitating an EEG. All of these cases should first be discussed with the on-call paediatrics team to decide if an EEG is indicated and appropriate follow-up of the result arranged (see management below). See EEG clinical prioritisation list.

EEG is not a useful screening test for epilepsy as a normal EEG can be seen in up to half of patients with epilepsy⁸. Similarly, EEG abnormalities can be seen in patients who do not have epilepsy and therefore do not confirm the diagnosis^5,7. It can, however, yield important information prior to first paediatric appointment, including diagnosis of a specific epileptic syndrome, making a diagnosis of (benign) focal epilepsy of childhood (as these children may only have a single episode) and assessing the diagnostic and management applications of brief seizures (such as absences and myoclonic jerks)^5,8. While an EEG is not routinely required in the investigation of a seizure it may be useful to help determine the seizure type and epilepsy syndrome⁷. The NICE guidelines recommend that an EEG be performed after the second seizure but can be considered after a first epileptic seizure following discussion with specialist⁷. Dr Panayiotopoulos clearly defined the advantages of an EEG after the first seizure, stating that the child and the family are entitled to a diagnosis, prognosis and management that is specific and precise, even though this may only be possible in a select-proportion of patients after the first seizure⁹.

Management

For management of a child who is actively seizing please refer to the Status Epilepticus Guideline.

The main priority in the child presenting after a seizure is to ensure their protection and optimise safety during the post-ictal period¹. Children should be placed in the recovery position and support provided for maintenance of airway and breathing if required³. Children should be monitored for further seizure activity and focal neurological signs as well as regular assessments made to ensure improvement in neurological status³. For disposition planning, please see Appendix 1: Disposition planning for patient with a First Afebrile Seizure flowchart.

Anti-Epileptic Drug Treatment

Anti-epileptic treatment is not usually commenced after a first unprovoked seizure⁵. However, there are specific circumstances where commencement after first afebrile seizure may be appropriate. Initiation of anti-epileptic treatment from Emergency should only be by the general paediatric team, following review and with appropriate medication counselling. These patients are subsequently referred for outpatient follow-up to ensure appropriate monitoring of medication effectiveness, side effects and titration of doses.

Disposition

When to escalate care

Children who present with ongoing or have a recurrence of seizures should be managed in an appropriate area with early senior emergency staff input. Please see the Status Epilepticus Guideline for further details. Patients with airway compromise as a result of decreased level of consciousness following a seizure require management in a resuscitation area with staff trained in airway management.

Features on history and examination necessitating early senior emergency staff involvement include:

• Persistent altered level of consciousness/encephalopathy (irritable, combative, sleepy)
• Decreasing level of consciousness
• Progressive neurological deficits
• Focal neurological deficits
• Seizure associated with trauma
• Clinical suspicion for non-accidental injury
• Clinical features of raised intracranial pressure
• Clinical features suggestive of intracranial infection

When to consider discharge

Children with an assessment suggestive of an unprovoked afebrile seizure who have returned to their baseline and have no other concerning features on assessment can be considered for discharge. It is important that all patients being discharged receive appropriate discharge education and have a plan for ongoing follow-up in place.

Discharge Education

Any patient who has had a seizure is at risk of another seizure⁴. Parents should be educated on the importance of increased adult supervision of their child, particularly for activities where a seizure will place the child at increased harm.

Examples of ways to minimise harm include:

• Avoiding baths and using showers instead for older children who will be bathing independently. Encourage safety glass, plastic or shower curtains for shower doors.
• Ensure supervision by an adult competent in swimming and life-saving when the child is in a swimming pool. The child should be encouraged to swim in the outside lane.
• Avoid activities at heights unless appropriate support (eg. Harness).
• Ensure adequate supervision of the child when riding a bike in traffic and where possible ride on bike paths rather than road.
• Minimise door locks within the home to prevent the child being locked in a room after a seizure. This is particularly important when showering.
• Strict no-driving rules if the child is of a driving age.
• Teachers and care-givers should be informed of the potential for another seizure to ensure appropriate supervision while not at home.
• If the child is old enough to walk to school they should have a companion.
• Avoid sleeping in the top bunk of a bunk bed.
• If the child is old enough to drink and carry hot liquids they are placed in a cup with a lid to avoid burns from spills.
• Helmets and protective guards should be used when riding a bicycle or scooter.

Parents and care givers should be educated on the recognition and management of a seizure⁷. Children should be laid on their side to prevent choking on saliva with pillows or cushions around their child to prevent injury from the hard floor or surrounding furniture. Parents should be advised not to prevent shaking during a seizure as well as from putting their fingers or other foreign objects in their child's mouth due to the risk of injury and airway obstruction. The duration of a seizure as well as the post-ictal period should be timed. Parents should be encouraged to attend first aid courses to assist with their knowledge on the management of a seizure or a post-ictal patient. Parents should also be empowered to call for emergency services assistance early⁴.

To help with further evaluation and management, parents should be encouraged to video further events if possible as well as keep a log of dates of events, associated symptoms and length of seizure. This is particularly important where diagnosis of the event is unclear or when specialist review is planned⁴.

A printable First aid for seizures handout is available and should be provided to parents on discharge.

Follow-Up

It is recommended that children presenting with an afebrile seizure have urgent outpatient follow-up to ensure precise and early diagnosis as well as initiation of therapy if appropriate⁷. A diagnosis of epilepsy is usually made by a specialist rather than in the emergency setting⁷. Patients should be discussed with the on-call general paediatric team as part of referral for a category one outpatient review. The need for outpatient neuroimaging and EEG can be discussed at the time and appropriate referrals made if appropriate.

When to consider admission

General Paediatric Team Admission

Indications for admission to a general paediatric team for further management and investigation include³

• Children < 6 months of age
• Prolonged seizures or status epilepticus
• Incomplete recovery
• Focal seizures
• Evidence of developmental delay
• Existing medical co-morbidities

Related documents

Guidelines

• Status Epilepticus Guideline
• Febrile Convulsion Guideline
• EEG clinical prioritisation form
• EEG request form

Factsheet and parent information

• Seizure handout
• PENNSW first seizure information