This is a blog post designed to disseminate the important work of Choosing Wisely, an initiative of the the American Board of Internal Medicine Foundation, the goal of which is the spark conversations between clinicians and patients about what tests, treatments, and procedures are needed – and which ones are not.

During your time in the Emergency Department you will encounter many children who have had a seizure. Most of them will have stopped seizing by the time they arrive to the ED, as is the case with simple febrile seizures (neurologically normal febrile 6-month to 5-year old children with a <15 minute generalized seizures that doesn’t recur within 24 hours) and unprovoked first time generalized seizures (that is, bilateral tonic and/or clonic movements). There are other situations in which the child will seize in front of you, these demand immediate attention from all parties involved, creating a sense of urgency. Team members and families eagerly await your intervention to halt the seizure and understand its underlying cause. Your team relies on your expertise as you outline a set of actionable steps to restore the patient to their previous baseline condition. Selecting the appropriate medications, if necessary, is of paramount importance. However, it is crucial to adopt a focused diagnostic approach to minimize unnecessary laboratory testing or CT scans whether the child seized in the ED or at home. These tests come with various costs, such as drawing your attention away from direct patient care, placing financial burdens on the patient, and even posing potential harm. This harm can manifest through the discomfort of blood draws and urine catheterizations, as well as the radiation exposure involved in head CT scans.

The lack of utility of laboratory testing in children with an unprovoked generalized seizure, or a simple febrile seizure is supported by several observational studies. The vast majority patients who have testing of their electrolytes (including glucose) have normal results. Unless the history suggests the likelihood of aberrant values you can omit labs. Urinalysis is similarly unhelpful unless part of a fever workup in a young child who is not yet potty trained. Urine drug screens do not test for all ingested substances, and the results of screens, though timely do not identify the toxindrome (sympathomimetic etc.) that you need to be addressing early in the patient’s course.

Similarly, head imaging rarely identifies abnormalities in children who have recovered after simple febrile or unprovoked first-time generalized seizures. In general the current evidence, which consists of observational studies, notes that the likelihood of identifying abnormal head CT findings in a child following the aforementioned types of seizures is low. This includes scarring abnormalities, bleeds, and tumors. A careful history and physical examination are ways that we as providers can “see what’s going on inside the head.” Explaining this to families is paramount – sometimes your exam is a test. In contrast, abnormalities on imaging are much higher in children with focal seizures or focal neurologic signs – with up to 50% having abnormalities seen on CT. For seizures MRI is generally the study of choice due to its superior anatomic resolution, identification of pathology, and lack of radiation risk. However, it is not yet readily available in the ED, and young children (especially under 6 years of age) may require general anesthesia which has its own inherent risks.

There are some situations where obtaining labs and imaging are warranted. One mnemonic that can be assessed in the first five minutes of a seizure is “FORGET”:  Fever, occult trauma, recurrent epilepsy, glucose, electrolytes, and trauma. 

Fever

First, is there a fever in a previously well child between the ages of 6 months and 5 years? Get a rectal temperature in younger children if you suspect the child feels warm, but your first temperature from an axillary, temporal, or tympanic temperature was normal.  If there is one – you might have a febrile seizure if the child returns to baseline shortly and has no other identifiable causes.  Other causes to consider during this visit include meningoencephalitis or abscesses in the central nervous system. 

Occult trauma

Any trauma that is not seen on your physical (e.g. battle sign bruises around the mastoid, raccoon eyes, or other bruising and lacerations) or reported by history – but could be identified (later) with a bleed or fracture on a head CT scan if your index of suspicion is high or the seizure is going well beyond the expected duration and not responding well to antiepileptics.  

Recurrent epilepsy

In children with known seizure disorders, a new seizure can be due to the seizure disorder itself as well as medication non-adherence, sub-therapeutic antiepileptic dosing, or a lowered seizure threshold due to an acutely ill state.  

Glucose

We all need it.  Because of their immature gluconeogenesis and inability to make appropriate decisions at times, children are even more susceptible than adults to getting hypoglycemia due to acute illnesses, decreased intake, ingestions (like beta-blockers, aspirin, alcohol, sulfonylureas), and other causes.  When hypoglycemia is corrected, this etiology has one of the most impressively fast improvements in clinical status. 

Electrolytes

Think about hyponatremia or hypernatremia (especially at <125 or >160, respectively), hypocalcemia, hypo/hyperkalemia, hypomagnesemia, or hypophosphatemia. The sodium, calcium, and potassium can be checked in settings with access to rapid point-of-care testing.  

Trauma

Major head trauma can cause seizures – and if you suspect it is the primary cause, start thinking about how to involve your surgical subspecialists early while you continue to support the patient medically.

Multiple evidence-based studies have shown that these tests do not significantly contribute to any changes in the management of these patients.  While it might feel “good” to you and the parents to be doing something for these patients – the mantra to follow for many patients is:  “Don’t just do something, stand there.” If the patient has a history of high-risk conditions (like sickle cell anemia, coagulopathies, neoplasm, or age <6 months), those patients might be at higher risk of comorbidities, and further testing or consultations with the appropriate specialist might be appropriate.  With good history taking and a chart review, most of these high-risk conditions are absent, and you have a young child in front of you who is playing with his parent’s smartphone again and moving around the exam room. Putting that child through the CT scanner unnecessarily increases their radiation exposure and risk of future cancers while also increasing their medical costs and extending their ED length of stay.   

Why do clinicians often order labs and head CT scans for these lower-risk patients who have returned to their baseline?  The causes are many – it could be a force of habit, a medical liability concern for “missing something,” a desire to please the caregivers, a previous seizure patient of theirs who had a bad outcome, or numerous other causes.  At times, these tests are certainly needed – but most times, use the diagnostic test of observing the patient over time – which decreases the risks of harm to the patient and focuses the healthcare team on actions that benefit the patient the most.   

The Choosing Wisely recommendation:  

Do not order laboratory testing or a CT scan of the head for a patient with an unprovoked, generalized seizure or a simple febrile seizure who has returned to baseline mental status

This episode of PEM Currents: The Pediatric Emergency Medicine Podcast approaches the topic from another angle and also discusses how we can avoid overuse of labs and CT scans in children with simple febrile and unprovoked seizures.

 

Gastroesophegeal Reflux and Gastritis – PEM Currents: The Pediatric Emergency Medicine Podcast

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, I explore the complexities of gastroesophageal reflux (GER) and gastritis in children and adolescents. I’ll make the important distinction between gastritis – which is diagnosed only via endoscopy – and dyspepsia, the term best used to describe the symptoms many patients experience. I’ll dive […]

1. Gastroesophegeal Reflux and Gastritis 27:00
2. ECPR 07:35
3. Syphilis 09:25
4. Cervical Spine Injuries
5. Febrile Seizures 27:22

References

Hirtz D, Ashwal S, Berg A, et al. Practice parameter: Evaluating a first nonfebrile seizure in children. Report of the Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society. Neurology. 2000; 55(5):616-623. Reaffirmed October 17, 2020

Riviello JJ Jr, Ashwal S, Hirtz D, et al; American Academy of Neurology Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: Diagnostic assessment of the child with status epilepticus (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2006;67(9):1542-1550 

American Academy of Pediatrics, Subcommittee on Febrile Seizures. Neurodiagnostic evaluation of the children with a simple febrile seizure. Pediatrics. 2011;127(2):389-394. DOI: https://doi.org/10.1542/peds.2010-3318 [doi.org]