Unprovoked Seizure Clinical Pathway — Emergency Department

Differential Diagnoses of Paroxysmal Events

Extensive, influenced by age and development, and varies from benign to serious etiologies.

Infancy	Benign sleep myoclonus Neonatal abstinence syndrome Breath-holding spells Sandifer syndrome/GERD Jittery/excitable
Childhood	Self-stimulatory behavior Tantrums Tics, stereotypies, movement disorders Vertigo Parasomnia/sleep disorders Psychogenic events
Adolescence	Complex migraine Panic attacks Periodic leg movements in sleep, parasomnia/sleep disorders Sleep disorders (periodic limb movements, parasomnias) Tics Vertigo Psychogenic nonepileptic events

Characteristics of Seizures vs. Syncope vs. Psychogenic Nonepileptic Events (PNEE)

The following table distinguishes seizures from syncope and psychogenic nonepileptic events, two of the more common seizure mimics.

	Seizure	Cardiac (Syncope)	Psychogenic Nonepileptic Events (PNEE) SSRD Pathway
Affected Age	Any age	Any age	Adolescence, occasionally childhood
Semiology	Multiple seizure types Tonic Clonic Myoclonic Atonic Epileptic spasm Focal (± altered awareness) Absence Emotional, cognitive, sensory	Sudden onset loss of consciousness, with pallor, atonia or diaphoresis	Interruptible, suppressible, or distractible Irregular jerking and thrashing Bilateral movement with retained consciousness Clenched eyelids Pelvic thrusting
Features	± aura Stereotyped events	Associated chest pain or shortness of breath Possible prodrome	History of abuse common
Triggers	Sleep deprivation	Fright (e.g., seeing blood or receiving injection) exercise, surprise, and immersion in water	Situational/stress
Typical Duration	Seconds – minutes	Seconds – minutes	Often prolonged 15-30 mins
Incontinence	Common	Uncommon	Uncommon
Tongue Biting	May occur – typically lateral	Rare	Uncommon
Recovery	Delayed (post-ictal)	Rapid	Rapid

Possible Causes of Provoked Seizure

Anatomical	Tumor/mass Stroke Congenital anomaly Neurocutaneous syndromes Sturge-Weber
Cardiac	Cardiomyopathy Prolonged QT Vasovagal syncope
Infection/Inflammatory	Febrile Seizure Gastroenteritis, e.g., rotavirus, shigella Meningitis Brain abscess or cerebritis Encephalitis Serious bacterial infection/Sepsis Autoimmune/vasculitis
Metabolic Abnormalities	Hypo/hyperglycemia Hypocalcemia Hyponatremia
Trauma	Impact seizures Traumatic brain injury (accidental or abusive)
Toxins/Drugs	Acute intoxication/overdose Drug/alcohol withdrawal Medication side effect

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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Unprovoked Seizure Clinical Pathway — Emergency Department

Differential Diagnoses of Paroxysmal Events

Characteristics of Seizures vs. Syncope vs. Psychogenic Nonepileptic Events (PNEE)

Possible Causes of Provoked Seizure

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Unprovoked Seizure — Differential Diagnoses — Clinical Pathway: Emergency Department

Unprovoked Seizure Clinical Pathway — Emergency Department

Differential Diagnoses of Paroxysmal Events

Characteristics of Seizures vs. Syncope vs. Psychogenic Nonepileptic Events (PNEE)

Possible Causes of Provoked Seizure