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You are seeing an 8 year old boy brought in by ambulance for a first time unprovoked afebrile seizure. The seizure was generalized tonic-clonic and lasted 3 minutes then self-resolved. The child is now back to baseline. A thorough history and physical exam has revealed no clear etiology for the seizure, and the neurologic exam is normal. The child was well prior to the seizure and has no significant past medical history. Blood glucose in the field was 98. The child is well-appearing and can easily obtain follow-up with his primary physician in a timely fashion.
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December 29, 2021 at 12:08 am
D) Referral for EEG as an outpatient
The American Academy of Neurology has released practice parameters for the evaluation and treatment of children aged 1 month to 21 years with first nonfebrile unprovoked seizure (https://www.aan.com/Guidelines/home/GuidelineDetail/88, https://www.aan.com/Guidelines/home/GuidelineDetail/100 ). Routine labs and LP are not recommended unless indicated by clinical history (e.g. vomiting / diarrhea). Similarly, ED CT scan is not recommended unless there is an indication such as focal seizure / focal post-ictal findings, or not returning to baseline within several hours. MRI is the preferred neuroimaging study. EEG is recommended, but typically done as an outpatient, not in the ED. Risks and benefits of anti-convulsant treatment generally do not favor starting treatment after the first seizure, and if treatment is to be started, phenobarbital is rarely the first choice therapy.