The patient’s circulatory status must also be closely monitored Seizures generally cause a massive sympathetic discharge that result in hypertension and tachycardia Continuous monitoring and intravenous (IV) access should be obtained Blood samples, including rapid blood glucose and sodium testing, should be acquired at this time Hypoglycemia should be corrected urgently, yet mild stress hyperglycemia during seizure episode usually does not require treatment Peripheral IV access, which is often difficult in the pediatric age group, may be nearly impossible in the actively seizing patient Intraosseous and/or central venous access may be required in the patient with prolonged seizures Once the respiratory and circulatory functions have been assessed and maintained, efforts should be directed at stopping any ongoing seizure activity and making a diagnosis As long as adequate ventilation and oxygenation are maintained, long-term sequelae are unlikely to result from a transient seizure Consensus management suggests the initiation of anticonvulsant treatment of anyone who has been seizing for more than minutes This likely represents all patients who are brought to the ED actively seizing EVALUATION AND DECISION History As a result of the numerous potential causes of seizures, as well as the large number of events that can be mistaken for a seizure, a focused history is important The parent or caregiver needs to carefully describe the episode and the preceding events Was there a warning (aura) that the patient was about to have an event? Was there a loss of consciousness, tongue biting, or incontinence? Did the event involve the entire body or only a portion? How long did the event last? How did the patient act after the event was over? The clinician should take into account that the event characteristics may not be accurately perceived by a distressed parent With smartphones and digital media being more common, parents may present a video clip of the event to the treating clinician, especially for recurring events In addition to the episode itself, the preceding events are also crucial Was there a history of trauma, toxin exposure or ingestion, fever, or other systemic signs of illness (e.g., headache, ataxia, vomiting, diarrhea)? Does the child have an underlying seizure disorder, history of seizures, or other neurologic problems? Is the child taking any anticonvulsants? If yes, was there a recent change in dose, or were any medications started or stopped? Is there a chance that the patient could have a subtherapeutic level, especially if there were any recently missed doses? Other questions that should be asked include if there was any other significant medical history (including abnormal developmental history), any significant surgical history (including the placement of a ventricular shunt), family history of seizures, other medication use, and travel history to an endemic region (neurocysticercosis is one of the leading worldwide causes of seizures) Planning for an Active Seizure The pediatric emergency physician should address the possibility of further seizure during the ED stay, especially in patients with a known seizure disorder admitted to the ED for a breakthrough seizure The history should focus on home medications that need to be administered and/or a possible medication load during the current visit An active seizure plan should be addressed Medication allergies or past adverse events, status epilepticus episodes in the past, or past medication failures, can guide the clinician toward a better tailored plan in some epilepsy patients Some patients may already have an active seizure/status epilepticus plan laid out by their primary neurologist Physical Examination With the history, a directed physical examination is performed to look for a possible cause of the seizure The examination should not be deferred until a postictal phase has resolved While limited in neurologic scope, a timely physical exam may identify a short-lived Todd paresis and other time-sensitive findings such as those related to trauma and/or ingestion Vital signs, including temperature, should be obtained An elevated temperature points to a potential infectious cause The entire body needs to be examined for the evidence of trauma, either as a preceding cause or as a result of falling during the seizure episode The skin should be examined for rashes or congenital skin lesions Dysmorphic features may be associated with other congenital CNS anomalies Stigmata of underlying hepatic, renal, or endocrinologic disorders should also be noted The head should be carefully examined for swelling, deformity, or other signs of trauma The presence of a ventricular shunt should be noted The pupils are studied for shape, size, reactivity, and equality The fundi are examined for the presence of retinal hemorrhages or papilledema The tympanic membranes are examined for the presence of hemotympanum or for a source of potential infection The mouth should be examined for the evidence of tongue biting The neck is assessed for meningeal irritation If there is a history or other physical signs of trauma, neck immobilization should be maintained until the C- spine can be thoroughly examined Examination of the chest, lungs, and abdomen is performed in the usual fashion The extremities are examined for the evidence of trauma, especially as the result of falling during a seizure The neurologic examination may be limited by either ongoing seizure activity or a postictal state and may consist solely of the pupillary examination, an assessment of any asymmetric movements (focality), and best response to stimuli Any abnormal posturing (decerebrate or decorticate) should be noted and dealt with immediately, with emergent imaging and possibly neurosurgical intervention During the postictal state, presence of a Todd paresis should be recorded If there is a question of a possible ingestion, the examination is also directed at uncovering a potential toxicologic syndrome (toxidrome) that may suggest a specific class of drugs or toxins that are responsible for the seizure (see Chapter 102 Toxicologic Emergencies ) Important variables include temperature, heart rate, blood pressure, pupil size, sweating, flushing, and cyanosis As the patient recovers from the seizure episode, periodic reassessment is needed to assess for any underlying neurologic abnormalities DIAGNOSTIC APPROACH Once it has been determined that a seizure may have taken place, the initial diagnostic evaluation (Fig 72.1 ) starts with the history and physical examination Laboratory, radiologic, and other neurodiagnostic testing (e.g., EEG) are other tools that can be a part of the seizure evaluation Patients with obvious trauma who are seizing should be treated per advanced trauma life support (ATLS) guidelines (see Chapter A General Approach to the Ill or Injured Child ), with close attention to possible intracranial injury (see Chapter 113 Neurotrauma ) Often, patients with a known seizure disorder will present to the ED actively seizing Patients known or suspected to be taking anticonvulsants should have drug levels evaluated A subtherapeutic anticonvulsant level is among the most common reasons for patients to present with seizures At times, a concurrent mild infectious process (URI, diarrhea) may have an effect on both seizure threshold and/or anticonvulsant absorption/metabolism Many different laboratory tests may reveal a cause for a seizure and, as a result, suggest a potential treatment A rapid glucose reagent strip test should be performed with the initial blood sample Hypoglycemia is a common problem that can often precipitate seizure activity If hypoglycemia is documented or a rapid assessment is not available, treatment with 0.25 to g/kg of dextrose is indicated Normal glucose levels should not necessarily be used to exclude hypoglycemia as the seizure cause as secondary stress hyperglycemia may occur over time as the seizure progresses Hyponatremia is a relatively common cause of seizures in infants, so a bedside rapid sodium test should be performed A febrile seizure is defined as a seizure caused by a fever, but this is a diagnosis of exclusion While the formal definition of the International League Against Epilepsy considers age range for febrile seizures to be month to years, most of the published data and PEM approach are limited to those months to years of age Caution should be used in labeling someone as having a febrile seizure outside of this age range Other infectious etiologies that present with a fever and can be the direct cause of a seizure (e.g., meningitis) must first be ruled out clinically Routine performance of a lumbar puncture (LP) for patients with either simple or complex febrile seizure is not required (see Chapters 31 Fever and 94 Infectious Disease Emergencies ) but rather is based on clinical findings Furthermore, infections not involving the CNS may still be the cause of the seizure through the elaboration of fever and inflammatory mediators Presence of fever and/or an elevated white blood cell (WBC) count may direct one to look for a potential infectious cause, yet stress response with peripheral leukocytosis occurs in up to a quarter of children with generalized seizures Blood cultures should be limited to those patients at risk for bacteremia Urinalysis and chest radiographs can also be used to confirm a source of infection ... (neurocysticercosis is one of the leading worldwide causes of seizures) Planning for an Active Seizure The pediatric emergency physician should address the possibility of further seizure during the ED stay, especially