TABLE 72.2 DIFFERENTIAL DIAGNOSIS OF PAROXYSMAL EVENTS Seizure disorders Psychogenic nonepileptic seizures (Pseudoseizures) Head trauma Loss of consciousness Posttraumatic seizures Syncope Hypovolemia Hypoxia Reduced cardiac output Sleep disorders Nightmares Night terrors Narcolepsy Sleep apnea hypersomnia Somnambulism Apparent life-threatening event Movement disorders Paroxysmal choreoathetosis Tic disorders Shudder attacks Benign myoclonus Psychiatric disorders Daydreaming Attention-deficit hyperactivity disorder Panic attacks Gastrointestinal disorder Sandifer syndrome (gastroesophageal reflux) Abdominal migraines Cyclic vomiting Breath-holding spells Pallid Cyanotic Atypical migraines Psychogenic nonepileptic seizures (PNES) were formerly called “pseudoseizures.” They are a movement disorder that resembles seizure activity, but have no corresponding abnormal brain electrical activity PNES include a wide array of conditions ranging from conversion reaction to movement disorder and even parasomnias When the event is psychogenic in nature, the movements can be quite startling, are typically bizarre and thrashing, and are often associated with a great deal of vocalization There is usually no biting, incontinence, or injury associated with PNES In contrast to seizures, PNES are rarely followed by a postictal period or postictal headache, and patients often possess a clear mental status after the event PNES should also be suspected when the episodes are almost always witnessed or heard and never during sleep, rather than occurring randomly, and if the eyes are closed during the episodes (the eyes are closed in less than 10% of actual seizures) In some cases, diagnosis may require long-term video and electroencephalographic (EEG) monitoring Further complicating the issue is that PNES are most likely to occur in patients with an underlying seizure disorder ( Table 72.2 ) Breath-holding spells are common, affecting 4% to 5% of all children (see Chapter 126 Behavioral and Psychiatric Emergencies ) They typically present between the ages of and 18 months and rarely persist past years of age The two types of breath-holding spells—cyanotic and pallid—have common features, including a period of apnea and an alteration in the state of consciousness Usually, some initiating event (e.g., pain, fear, agitation) triggers the episode The diagnosis is based on the clinical findings, and the prognosis is excellent A variety of movement disorders can also mimic seizures Paroxysmal choreoathetosis is often associated with a positive family history for seizures and is exacerbated by intentional movement Tic disorders can be manifested by twitching, blinking, head shaking, or other repetitive motions These are usually suppressible and are not associated with any loss of consciousness Shudder attacks are whole-body tremors similar to essential tremor in adults Benign myoclonus of infancy can look like infantile spasms but is associated with a completely normal EEG Sleep disorders, such as somnambulism, night terrors (preschool-aged children), and narcolepsy (typically in adolescents) can often be diagnosed on the basis of the history alone (see Chapter 126 Behavioral and Psychiatric Emergencies ) Infants with gastroesophageal reflux may exhibit torticollis or dystonic posturing (Sandifer syndrome) Atypical migraines and PNES are often diagnosed after other causes are excluded INITIAL STABILIZATION This section will focus on patients with generalized convulsive status The first priority in the seizing patient is to address airway, breathing, and circulation (see Chapter A General Approach to the Ill or Injured Child ) An adequate airway is necessary to allow for effective ventilation and oxygenation Patients with impaired consciousness are at risk for obstruction (the tongue, oral secretions, emesis), aspiration (loss of protective reflexes), and hypoventilation Simple maneuvers such as the jaw thrust or suctioning of the oropharynx may improve the compromised airflow The use of adjunctive airways (oral or nasopharyngeal) may also help maintain an adequate airway In patients who are actively seizing, it may be difficult to insert these adjuncts and may cause injury if the intervention is forced Furthermore, in patients for whom trauma is a possibility, these maneuvers must be undertaken with cervical spine (C-spine) immobilization In patients in whom the airway remains unstable despite these actions, endotracheal intubation is warranted When it is necessary to use a muscle relaxant to intubate a seizing patient, one should use the shortest-acting agent possible The presence of motor activity may be the only clinical manifestation of seizure, and a longacting muscle relaxant will mask the ongoing seizure activity One should consider alternatives to succinylcholine in the setting of prolonged seizures because of the potential risk of hyperkalemia related to rhabdomyolysis While securing the airway takes priority over other clinical assessment elements, one will lose the ability to assess whether the clinical seizure activity has stopped in a medically paralyzed child Parameters such as heart rate are notoriously unreliable Missed “iatrogenic nonconvulsive status epilepticus” will result in neuronal death despite lack of clonic or tonic features The clinician must consider interventions to avoid these dilemmas For example, a patient may have a potentially short-lived apneic episode following the rapid administration of a benzodiazepine When possible, such a drug should be administered over to minutes rather than rapid infusion, and short apneic/hypopneic episodes that may follow can often be managed with a short period of bag–mask ventilation prior to endotracheal intubation If endotracheal intubation does take place, many institutions offer an urgent limited-lead EEG that can help evaluating background activity for possible ongoing seizure If not available, an emergent EEG should be obtained Intubated patients often receive continuous infusions of a benzodiazepine after endotracheal intubation to maintain sedation However, continuous infusions of benzodiazepines may also be used in the treatment of refractory seizures Aligning the dose of a benzodiazepine infusion with the latter protocol may further mitigate the risk of ongoing “subclinical” seizure and neuronal death