Neobook — clinical reference

Authors: Dr Jo Wilmshurst & Dr Sally Ackerman

Section Editor: Dr Baljit Cheema

Summary Algorithm
History/examination
Indications for referral to Paediatric OPD
Indications for admission and referral to paediatrics
Advice for caregivers
Indications for neuroimaging
Indications for EEG
Indications for lab investigations

Summary Algorithm

Click on image to enlarge

Note: If seizure onset was unwitnessed, follow the flow chart for generalised seizures.

If in doubt, or concerns regarding high risk for further seizures discuss with local paediatric team or referral centre team as appropriate.

Note: Children over the age of two years who have had only one seizure and have none of the indications for admission** or indications for imaging ¹ or EEG² below do not require referral for out-patient EEG or neuroimaging.

ADDITIONAL NOTES:

History/examination:

1. Obtain as detailed a history as possible regarding the event at the time of presentation.

Targeted history in order to ascertain the following:

Was the event a seizure? Be aware of seizure mimickers including breath holding spells, syncope etc.
Was the event the first epileptic seizure? Enquire about prior seizures; these may have looked different to the current event and therefore go unrecognised e.g. absences, myoclonic jerks, drop attacks.
The specific circumstances and characteristics of the seizure – occurrence day or night, specific questioning to reveal focal onset, duration and whether there were any provoking factors – e.g. head injury, flashing lights. Note that sleep deprivation may reduce threshold for seizures but is not considered a provoking factor.

2. Search for a cause (history and examination)

Includes: hypoglycaemia, electrolyte disturbances (diarrhoea/vomiting), malignant hypertension (various causes), possible substance ingestion including accidental/intentional ingestion of prescription or recreational drugs and toxins, head trauma (accidental or non-accidental). Note that infection may be present without fever.
Past medical history or examination may reveal a structural cause requiring acute intervention E.g.: stroke, granuloma, space occupying lesion, cyanotic cardiac lesion -> REFER PAEDIATRICS & MANAGE ACCORDINGLY
PMH or examination may reveal a structural cause with a high risk of recurrence but not requiring acute/ emergency intervention e.g. a pre-existing brain abnormality or prior static insult such as birth asphyxia/ prior meningitis -> REFER PAEDIATRIC OPD
PMH may reveal other factors with a high risk of recurrence (e.g. previous febrile seizures or a first degree relative with childhood onset epilepsy) - > REFER PAEDIATRIC OPD

All children presenting with an afebrile seizure must have their glucose checked as soon as possible following presentation and their blood pressure measured during the acute presentation

Indications for referral to Paediatric OPD (if the child has fully recovered and has NO indications for admission)

If there is a history of more than one seizure – REFER TO PAEDIATRIC OPD
If there is a history of more than one seizure type OR one or more afebrile seizures AND <24 months age then REFER TO PAEDIATRIC OPD URGENTLY or if available PAEDIATRIC NEUROLOGY SERVICE

Indications for admission and referral to paediatrics

Impaired consciousness more than 1 hour post seizure (consider impact of medications used to terminate seizure)
New neurological signs
Clinical signs of raised intracranial pressure
Systemically or generally unwell e.g. irritability, listlessness
Meningism
Prolonged (>15 minutes) or recurrent (within 24 hours) seizures
Signs of possible aspiration e.g. Respiratory distress/clinical pneumonia without prior symptoms/oxygen requirement
Clinical indicators requiring neuroimaging ¹
Clinical indicators requiring urgent EEG²
Clinical indicators requiring lab investigation³
History of neuro-regression (motor or language/cognitive)
Less than 24 months age or focal seizures at any age – low threshold for admission and referral particularly if impractical/unlikely to return to Paediatric OPD for further evaluation/workup
High caregiver anxiety/ caregiver not willing to take home or difficulty returning to hospital

Advice for caregivers

Return if following discharge one or more of the following:
- altered level of consciousness
- persistent headache or vomiting
- further seizure/s (NB: some parents mistakenly think they do not need to return for further seizures as the child has already been seen. Therefore emphasise that they must return for review as further seizures may require further investigation or treatment)
- other motor/cognitive decline
Reinforce basic seizure management i.e.: recovery position, never attempt to put anything into the child’s mouth, wipe away any secretions only, do not delay seeking help if seizure persists > 5 minutes; parents should access nearest medical centre for emergency treatment
Reinforce precautions: The child should not be left unsupervised in or near open water even if they are able to swim (this includes bathwater) for at least the first 3 months post seizure

¹Indications for neuroimaging

Urgent in any child with a post ictal focal deficit which does not resolve fully within 30 minutes or who has not returned to baseline within several hours after the seizure (effects of medication used to abort seizure need to be taken into consideration)
Non urgent: (Refer Paediatric out patients)
- seizure of focal onset with or without secondary generalisation in whom there is no persistent focal deficit (see above)
- any child with significant developmental delay (motor impairment or cognitive disability) of unknown cause and not previously investigated
- children under age 24 months without any of above indications for urgent imaging

²Indications for EEG (AAN guidelines⁽²⁾recommend a non-urgent EEG for all children after a first non-febrile seizure however in resource limited settings the following are the minimum recommended indications for an EEG)

Urgent EEG:

A child with continuing altered level of consciousness in whom sub-clinical status epilepticus cannot be ruled out
Infantile spasms or suspected infantile spasms (admit and refer urgently to paediatrics)

Non-urgent EEG (refer via Paediatric out-patients/Paediatrician to ensure ongoing care):

A child with recurrent seizures (includes a new non-febrile seizure on a background of previous febrile seizures
A child with a history of more than one type of seizure
Language regression between ages 2 – 7 years, suspicious of Landau Kleffner syndrome with or without accompanying seizures
Children under age 24 months

³Indications for lab investigations (not indicated for children older than 6 months if seizure clearly unprovoked and no other clinical indicators for bloods or CSF)

A history of diarrhoea or vomiting
History suggestive of possible electrolyte disturbances (e.g.: renal, liver, cardiac patient, relevant medication)
Toxicology screen if history suggestive
CSF should be performed in children under 6 months age OR in those with meningeal signs or other signs suggestive of intracranial infection OR in the child with fever under 18 months age
NOTE: CSF should only be performed provided there are no contra-indications

^##IV Fluids:

1/2 Darrows Dextrose is recommended as maintenance fluid therapy while awaiting transfer if serum electrolytes not known: Note: Avoid overzealous fluid administration unless specifically replacing losses

For children who have had prolonged seizures or remain neurologically obtunded discuss with paediatric team and/or referral centre

Abbreviations: AAN: American Academy of Neurology

References:

Baumer JH. Evidence based guideline for post-seizure management in children presenting acutely to secondary care. Arch Dis Child 2004; 89: 278–280.
Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P. Practice parameter: Evaluating a first non-febrile seizure in children. Neurology 2000; 55.
Wiebe S, Tellez-Zenteno J, Shapiro M. An evidence – based approach to the first
seizure. Epilepsia 2008; 49(Supp.1): 50-57.