Take a look at these three seizure cases that were first discussed with our residents this month. I’ll post my thoughts and additional learning resources very soon.
A 9 month old female presents after having a 3 minute seizure via EMS. She stopped seizing when EMS arrived. No prior significant health issues. vaccines are up to date. In the ED she has a temp of 39.3, is fussy but consolable and other than nasal congestion and a HR in the 170s has an unremarkable physical exam.
This is a simple febrile seizure. Ultimately if she has a normal neurologic examination and a reassuring appearance and mental status you can discharge home with good anticipatory guidance. Check out my six part febrile seizure series for more information.
The Febrile Seizure Series
A seizure is one of the scariest things a parent can witness. Concordantly it is important to develop your skills in counseling families on the diagnosis and management at home. This video details the way that I talk to families about simple febrile seizures.
An 8 year old male brought in by EMS after he had 4 minutes of generalized convulsions at school that happened 45 minutes ago. He was sitting at his desk in class and cried out before slumping over in his chair and eventually to the floor. His “eyes rolled back” and he had rhythmic shaking of all of his extremities. Past history is significant for ADHD on Concerta. No loss of bowel or bladder continence. He is sleepy but arousable. His vitals are normal and he is afebrile.
This patient had a first-time unprovoked seizure. Given that epilepsy occurs in 1/100 people this is not unexpected from time to time in the Pediatric ED. Ultimately, the unofficial maxim “you get one” hold here, and if the child’s neurologic examination and mental status are normal in <2 hours after the seizure you can discharge home. Neurology follow up is recommended, and EEG and possibly MRI will be helpful. Generally most seizures are <5 minutes (most 2 minutes) and thus rectal or buccal benzos are not necessarily warranted as a prescription AED at the time of discharge.
A 15 year old female was at color guard practice when she states that she felt dizzy then her vision blacked out and she was reported to have fallen to the ground. Her eyes rolled back in her head and all of her limbs “stiffened up” for about 30 seconds. She was attended to by a teacher and woke up within 2 minutes of falling. She asks “what happened.” EMS was called and her glucose was 71. Exam reveals an anxious teen with normal vitals and an unremarkable exam.
This teen had convulsive syncope, which may happen in 40% of patients that faint! An EKG and pregnancy test are generally the only other interventions necessary in cases like these. You can read more about convulsive syncope in the eponymous post.
