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Evaluation and treatment of a first unprovoked seizure with end of visit information

Evaluation

If an event occurs that is most likely to be a seizure: [Hirtz: 2000]
  • Rule out acute symptomatic causes, e.g., meningitis, toxic ingestion. If no acute etiologies are found, the seizure is said to be unprovoked. This type of seizure includes idiopathic seizures, thought to be genetic in origin, remote symptomatic seizures (e.g., in a child with known long-standing cerebral palsy), and cryptogenic seizures (no obvious cause).
  • Obtain a detailed history and physical (see Seizure assessment tool (PDF Document 41 KB) for an assessment algorithm);
  • Consider laboratory studies such as blood glucose, toxicology, blood chemistries, but only as suggested by clinical history or physical exam in a child older than 6 months ;
  • Consider performing a lumbar puncture if the child has altered mental status or meningeal signs or is younger than six months of age, but this is usually not necessary otherwise;
  • Schedule an EEG to be performed on an outpatient basis some time after the seizure, as it might be helpful in determining seizure type, epilepsy syndrome and hence recurrence risk - EEGs performed very soon after the seizure are often abnormal and might be difficult to interpret ; and
  • Consider imaging, preferably an MRI. This can usually be done on an outpatient basis. Imaging may be helpful in determining seizure etiology, especially if the seizure had a focal onset (eye deviation to one side, one side of the body, etc.).

Treatment

  • As only a small percentage of children with a first unprovoked seizure have another seizure, most providers will wait for a second seizure before starting medication although this decision will depend on seizure length, family preference, etc..
  • The decision regarding whether or not to treat a child with antiepileptic drugs after a first seizure must weigh the risks of having a second seizure versus the side effects and possibly psychosocial aspects of being on daily medication. Waiting to treat until a second seizure allows a better clarification of events, and allows the event frequency to be determined.
  • Treatment with AEDs may prevent a second seizure, but starting medication is not a guarantee that the child will not have another seizure. [Hirtz: 2003]
  • There is no evidence that treatment with AEDS prevents the development of epilepsy, and no evidence that not treating increases the risk of developing epilepsy.
  • Levetiracetam is a possible drug of first choice in this situation as it has few side effects and few drug interactions. Levels and screening laboratory testing are not performed with this medication. When it is used, the dosage is 10 mg/kg bid times 1 week, then 20 mg/kg bid po, with a usual maximum of 30 mg/kg bid. If levitiracetam is not successful at the maximum dose, another medication will usually be necessary. The prescribing physician should familiarize themselves with all prescribing information.

Discharge Instructions

Before the child is discharged from the clinic, emergency department, or hospital, the following information should be covered with the family:
  • Discuss seizure activity restrictions with the child and family as appropriate. See Activity Restrictions in Children with Seizures.
  • Follow-up should be arranged either with the child's Medical Home clinician or with a pediatric neurologist.
  • A seizure action plan should be developed with the family. This includes what to do if there is another seizure, and if the seizure was prolonged, directions for rescue medication in case of another prolonged seizure. Either rectal diastat or nasal midazolam can be prescribed ifor seizures lasts longer than 5 min.
    • See Valium - rectal information (Diastat.com) for diastat dosing, which varies by age, and other information.
    • Nasal midazolam is given at a dose of 0.2 mg/kg divided in half, with half given to each nostril by a mucosal atomizer device. One "kit", which is what is used at each administration, consists of the total dosage divided into two syringes that each have 2 mucosal atomizer devices (MADs). Often, pharmacies need to special-order the MADs.
  • Information regarding the anti-epileptic medication presribed, if any.
  • Information regarding seizures given to the family. See for an example, Lets talk about...seizures (Primary Children's Medical Center).

Resources

Practice Guidelines

Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, Shinnar S.
Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society.
Neurology. 2000;55(5):616-23. PubMed abstract / Full Text
Recommendations are based on a three-tiered scheme of classification of evidence found in literature review.

Hirtz D, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Gaillard WD, Schneider S, Shinnar S.
Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology. 2003;60(2):166-75. PubMed abstract / Full Text
This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are also reviewed.

Patient Education

Lets talk about...seizures (Primary Children's Medical Center)
This link will bring you to the Lets Talk About neurology series from PCMC. Scroll down to the Seizures link. This handout is available in English and Spanish.

Tools

Seizure assessment tool (PDF Document 41 KB)
Questions to ask about signs and symptoms before, during and after a seizure from the American Academy of Neurology (2000).

Seizure history & physical form (PDF Document 88 KB)
Offers a format and reminders for performing and recording the physical exam for the child with seizures.

Services

Pediatric Neurology

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Authors

Author: Lynne M Kerr, MD, PhD - 6/2011
Content Last Updated: 6/2011

Page Bibliography

Hirtz D, Ashwal S, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Elterman R, Schneider S, Shinnar S.
Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society.
Neurology. 2000;55(5):616-23. PubMed abstract / Full Text
Recommendations are based on a three-tiered scheme of classification of evidence found in literature review.

Hirtz D, Berg A, Bettis D, Camfield C, Camfield P, Crumrine P, Gaillard WD, Schneider S, Shinnar S.
Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society.
Neurology. 2003;60(2):166-75. PubMed abstract / Full Text
This parameter reviews published literature relevant to the decision to begin treatment after a child or adolescent experiences a first unprovoked seizure and presents evidence-based practice recommendations. Reasons why treatment may be considered are discussed. Evidence is reviewed concerning risk of recurrence as well as effect of treatment on prevention of recurrence and development of chronic epilepsy. Studies of side effects of anticonvulsants commonly used to treat seizures in children are also reviewed.