Pediatric Hospital Medicine

17

Chapter 2 • Seizure

TABLE 2.10 HIGH-VALUE APPROACH TO FIRST-TIME UNPROVOKED SEIZURE DIAGNOSTIC STUDIES TREATMENT DO DON’T DO DON’T • Detailed history and physical • EEG within 24 h to de • Lumbar • Supportive care • Rule out

• Initiate anti

puncture (unless specific indications exist)

epileptic drugs. 1,5

termine if seizure is epi leptic and classify seizure type 4

seizure mimics. • Follow course longitudinally and consider risks of ac tivities such as driving and swim ming, and potential ter atogenicity of medications.

• Labs

• Serum

• CBC • CMP, including

prolactin • Creatine kinase 4

magnesium, phosphorus • Urine toxicology screen • MRI brain if focal neuro logic exam or prolonged loss of consciousness • Evaluation by pedi atric neurologist or epileptologist 2,4

CMP, complete metabolic panel; CBC, complete blood count; EEG, electroencephalogram; LP, lumbar puncture; MRI, magnetic resonance imaging.

■ MANAGEMENT Management of first-time unprovoked seizure is largely supportive and aimed at determining whether the event is epileptic in origin. Antiepilep tic drugs are not recommended as they have not been shown to decrease recurrence of seizure, affect prognosis or diagnosis of epilepsy, or de crease seizure-related death. Furthermore, only 10% of those with first time seizure develop epilepsy regardless of treatment. Pediatric patients with first-time unprovoked seizure should be evaluated by a specialist with training in pediatric epilepsy to enhance diagnostic accuracy. 5 ■ REFERENCES 1. Stroink H, Brouwer OF, Arts WF, Geerts AT, Peters AC, van Donselaar CA. The first un provoked, untreated seizure in childhood: a hospital based study of the accuracy of the diagnosis, rate of recurrence, and long term outcome after recurrence. Dutch study of epilepsy in childhood. J Neurol Neurosurg Psychiatry . 1998;64(5):595-600. 2. Hamiwka LD, Singh N, Niosi J, Wirrell EC. Diagnostic inaccuracy in children referred with “first seizure”: role for a first seizure clinic. Epilepsia . 2007;48(6):1062-1066.

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