Unprovoked Seizure — Evaluation Considerations — Clinical Pathway: Emergency Department

Unprovoked Seizure Clinical Pathway — Emergency Department

Further Evaluation Considerations

  • In general, laboratory studies, emergent EEG, and emergent imaging studies are not needed for an unprovoked seizure
  • Most children should undergo outpatient routine EEG and outpatient diagnostic MRI (seizure protocol) if etiology unknown and not a definite epilepsy syndrome
  • Based on clinical concerns, a head CT followed by MR brain screen or non-emergent full diagnostic brain MRI may be indicated
  • Neurology Consultation may be beneficial for children requiring additional evaluation
Emergent
Head Imaging
  • Persistently altered mental status
  • New focal neurologic sign
  • Prolonged Todd’s Paralysis (> 15 min)
MR Brain Screen Concern for ischemic/metabolic stroke or posterior reversible leukoencephalopathy syndrome (PRES)
Head CT Concern for abusive head trauma, traumatic brain injury, intracranial hemorrhage (including hemorrhagic stroke), mass, or signs of increased intracranial pressure
Diagnostic MRI
  • MRI with contrast may be a component of the acute evaluation for encephalitis
  • Should be discussed with neuroradiology
EEG Persistently altered mental status to assess for ongoing electrographic seizures
Laboratory Studies
  • POC glucose if hypoglycemia suspected
  • Toxicology screens for suspected ingestion
  • BMP if substantial losses (vomiting, diarrhea), suspicion of metabolic derangement, or suspected incorrect formula mixing in infant
  • CMP, ammonia, UA for suspected inborn error of metabolism
Lumbar Puncture
ECG Possible cardiogenic etiology, e.g., convulsive syncope