Anxiety following a child's first unprovoked seizure often leads to extensive diagnostic testing in the emergency department, even if the child has returned to baseline. Usually, few diagnostic tests are needed following a first unprovoked seizure. A practice parameter from the American Academy of Neurology and the Child Neurology Society addresses these situations . In the emergency department, a toxicology screen is reasonable. Measuring electrolytes and glucose levels is not required if the seizure has stopped and the child has returned to baseline and is not dehydrated. Except in selected cases, neuroimaging is not helpful in the emergency department [3, 4]. A hospital-based study in Boston made the following recommendations, based on 500 children presenting to the emergency department with a first-time seizure: emergent imaging with head computed tomography (CT) scan should be undertaken in children with a known bleeding or clotting disorder, a known history of malignancy, human immunodeficiency virus (HIV) infection or closed head injury, as well as in patients aged less than 33 months with a focal seizure .
In most cases, an electroencephalogram (EEG) is not needed in the emergency department, but should be obtained within 1 week after a first unprovoked seizure. Because some paroxysmal spells in children may be difficult to diagnose based on history alone, an abnormal EEG may help support the diagnosis of a seizure. However, a normal EEG in no way excludes the diagnosis of a seizure. An interictal EEG may also help to distinguish between focal-onset and generalized-onset seizures, which affects medication selection if the child goes on to develop epilepsy.
In addition, the interictal EEG provides valuable information regarding the risk of seizure recurrence. In a long-term, prospective cohort study in the Bronx, normal children with normal EEGs after a single unprovoked seizure had seizure recurrence rates of 28% and 32% at 2 and 5 years, while normal children with abnormal EEGs had seizure recurrence rates of 52% and 59% at 2 and 5 years. Not surprisingly, children with developmental disabilities and an abnormal EEG have an even higher risk of recurrent seizures .
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