Signs and Symptoms Acute Ataxia: Chapter 15 Coma: Chapter 17 Dizziness and Vertigo: Chapter 24 Eye: Visual Disturbances: Chapter 30 Hearing Loss: Chapter 34 Limp: Chapter 46 Neck Stiffness: Chapter 49 Pain: Headache: Chapter 59 Seizures: Chapter 72 Vomiting: Chapter 81 Weakness: Chapter 82 Medical, Surgical, and Trauma Emergencies Neurotrauma: Chapter 113 Neurosurgical Emergencies: Chapter 122 SEIZURES (SEE ALSO CHAPTER 72 SEIZURES ) Goals of Treatment Most seizures in children are brief, lasting less than minutes Status epilepticus (SE) was classically defined as seizures that are continuous for 30 minutes or longer or repetitive seizures between which the patient does not regain consciousness Many authorities now consider that seizures lasting for longer than minutes or multiple seizures with no return to baseline in between constitute early SE Initial management of the child with a seizure is directed at preventing neurologic damage through supportive care and seizure termination with timely administration of antiepileptic drugs (AEDs), as well as identifying any treatable underlying cause of the seizure CLINICAL PEARLS AND PITFALLS Status epilepticus should be treated aggressively to minimize neurologic damage Routine laboratory studies and acute neuroimaging are unnecessary for the majority of children with first-time seizures Current Evidence Epidemiologic studies indicate that 3% to 6% of children will have at least one seizure in the first 16 years of life; most of these are simple febrile seizures, which generally occur in children months to years old A seizure is a transient, involuntary alteration of consciousness, behavior, motor activity, sensation, and/or autonomic function caused by an excessive rate and hypersynchrony of discharges from a group of cerebral neurons The term convulsion is often used to describe a seizure with prominent motor manifestations Epilepsy, or seizure disorder, is a condition of susceptibility to recurrent seizures The basic pathophysiologic abnormality common to all seizures and convulsions is the hypersynchrony of neuronal discharges Many precipitating factors, including metabolic, anatomic, and infectious abnormalities (see Chapter 72 Seizures ), may produce seizures Seizures that result from an identified precipitant are called symptomatic, or provoked, seizures, whereas those with no precipitating factor are called idiopathic or cryptogenic Febrile seizures (seizures occurring in association with a febrile illness, without evidence of intracranial infection or other identified cause) are a particular type of provoked seizure seen in children between the ages of months and years The exact cause of febrile seizures remains elusive Elevated body temperature lowers the seizure threshold, and the immature brain appears to have a particular susceptibility to seizures in response to fever Individual predisposition plays an important role During a seizure, cerebral blood flow, oxygen and glucose consumption, and carbon dioxide and lactic acid production increase dramatically If the patient remains well ventilated, the increase in cerebral blood flow is sufficient to meet the increased metabolic requirements of the brain Brief seizures rarely produce lasting deleterious effects on the brain; however, prolonged and serial seizures, especially SE, may be associated with permanent neuronal injury Clinical Considerations Clinical Recognition When the physician is examining a child with an acute paroxysmal event, the first step is to distinguish seizures from other nonepileptic phenomena If the event is indeed a seizure, it may be classified according to type Finally, a specific causative factor should be sought The extent of the emergency evaluation is determined by the clinical scenario; some of the diagnostic assessment may be deferred Of course, when a child is actively seizing, the first priority is to provide necessary resuscitation measures and control the seizures (see Chapter 72 Seizures and the following sections) Paroxysmal events other than seizures that involve changes in consciousness or motor activity are common during childhood and may mimic epilepsy ( Tables 67.1 and 97.1 ) Breath-holding spells occur in children months to years of age Breath-holding spells take two forms: cyanotic and pallid In the cyanotic form, the infant begins crying vigorously, often in response to an inciting event, then holds his or her breath and becomes cyanotic After approximately 30 to 60 seconds, the child becomes rigid As the spell ends, the child becomes limp and may have a transient loss of consciousness and twitching or jerking of the extremities, but the child quickly returns to full alertness A pallid breath-holding spell may follow a seemingly insignificant trauma The child may start to cry, but then turns pale and collapses There is a brief period of apnea and limpness, followed by rapid recovery In both types of breath-holding spells, the typical history and lack of postictal drowsiness help determine the diagnosis Breathholding spells may be recurrent but disappear spontaneously before school age Syncope is a brief, sudden loss of consciousness and muscle tone There are numerous causes of syncope, many of which can be detected on the basis of historical information, physical examination, and simple diagnostic tests (see Chapter 76 Syncope ) A syncopal episode can usually be distinguished from a seizure on the basis of the description The child is typically upright before the event and often senses a feeling of light-headedness or nausea The child then becomes pale and slumps to the ground Syncope can sometimes be accompanied by brief seizure-like movements The loss of consciousness is short-lived, and recovery is rapid This is in contrast to seizures, which usually have a postictal period with sleepiness On awakening, the child is noted to have signs of increased vagal tone, such as pallor, clammy skin, dilated pupils, and relative bradycardia Patients with narcolepsy also experience sudden alterations in alertness, with sleep occurring suddenly and uncontrollably during the daytime In about half of the patients, narcolepsy is associated with cataplexy, an abrupt loss of muscle tone brought on by a sudden emotional outburst Narcolepsy is far less common than syncope; both occur more often in adolescents than in younger children TABLE 97.1 NONEPILEPTIC EVENTS THAT MAY MIMIC SEIZURES Breath-holding spells Syncope Migraine Jitteriness Benign myoclonus Shuddering attacks Tics Acute dystonia Gastroesophageal reflux Night terrors Sleep paralysis Narcolepsy Pseudoseizures Single episodes of staring, involuntary movements, or eye deviation have been found to occur commonly in the first months of life, although they rarely lead to the parent seeking medical attention In some children, however, these episodes occur frequently Children with benign shuddering attacks have episodes of staring and rapid tremors involving primarily the arms and head, sometimes ... classified according to type Finally, a specific causative factor should be sought The extent of the emergency evaluation is determined by the clinical scenario; some of the diagnostic assessment may