Pediatric seizures are common. So common that about 5% of all children will have a seizure by the time they’re 16 years old. If any of you have been parents of a child who suddenly starts seizing, you’ll know intimately how terrifying it can be.

While most of the kids who present to the ED with a seizure will end up being diagnosed with a benign simple febrile seizure, some kids will suffer from complex febrile seizures, requiring some more thought, work-up and management, while others will have afebrile seizures which are a whole other kettle of fish. We need to know how to differentiate these entities, how to work-them up and how to manage them in the ED. At the other end of the spectrum of disease there is status epilepticus – a true emergency with a scary mortality rate - where you need to act fast and know your algorithms like the back of your hand. This topic was chosen based on a nation-wide needs assessment study conducted by TREKK (Translating Emergency Knowledge for Kids), a collaborator with EM Cases.

With the help of two of Canada’s Pediatric Emergency Medicine seizure experts hand picked by TREKK, Dr. Lawrence Richer and Dr. Angelo Mikrogianakis, we’ll give you the all the tools you need to approach the child who presents to the ED with seizure with the utmost confidence.

Written Summary and blog post Prepared by Michael Kilian, edited by Anton Helman, Nov 2015
Step 1: Distinguish Pediatric Seizures vs. Pediatric Seizure mimics
Much of the distinction between true pediatric seizures and mimics will hinge on elements gathered from the history. Ask about the onset, duration, nature of the movements, tongue biting, eye findings and details of the recovery phase. A history of incontinence can be helpful in older children who are no longer in diapers. The presence or absence of an aura will only be helpful in children who are able to provide a clear account of their experience. Be sure to ask the parents what the eyes, neck and head were doing at the time of the seizure. The recovery phase is also important since a rapid return to normal activity speaks against a true seizure.

Elements that are highly suggestive of true seizure activity include:

* Lateralized tongue-biting (high specificity)
* Flickering eye-lids
* Dilated pupils with blank stare
* Lip smacking
* Increased heart rate and blood pressure during event
* Post-ictal phase

 

Distinguishing Breath-holding spells from Pediatric Seizure

Breath holding spells are most common in the 6-18month age range. One of the key differentiating factors is that there is usually a clear trigger for a breath holding spells such as emotional distress or pain, whereas seizures typically do not have such precipitants. This pattern of an initiating trigger, followed by emotional upset, crying, pallor, and occasionally LOC is highly suggestive of a breath holding spell. The breath holding and LOC can lead to brief seizure activity given the decrease cerebral blood-flow. However, the recovery from a breath-holding spell is rapid and complete without a post-ictal phase.

 

Distinguishing Pseudo-Seizures from True Seizure

These tend to be seen in the adolescent population since younger children cannot feign seizure activity for secondary gain. Features that distinguish these events from true seizures include side-to side head, arm or leg movements with eyes closed. If the eyes are open, the eye movements are normal as opposed to deviated. A bicycling movement of the legs is highly suggestive of pseudo-seizure.

 

Distinguishing Syncope from Seizure

Syncopal episodes may or may not have a clear precipitant but the LOC always precedes any perceived seizure ac...