The First Seizure

The first seizure in a child usually causes some degree of panic in the parents, and an accurate description of the seizure and preseizure events may not be obtainable. If it lasts seconds to minutes, and if others in the family have experienced seizures, an emergency visit may not be made. Unless the child is in status epilepticus, or seizures recur in the emergency department (Iablel121l:2), the physician can defer immediate anticonvulsant treatment and concentrate on defining the cause and the risk of recurrence (Fig 121-1).

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TABLE 121-2 Critical Pathway: New-Onset Seizure with Neurological Compromise

FIG. 121-1. New onset seizure. General treatment plan.

Hauser and coworkers2 categorized seizure recurrence for all ages according to the presumed cause. Of their patients, 73 percent were categorized as having idiopathic seizures and 27 percent as having remote symptomatic seizures. Idiopathic seizures recurred in 17 percent of the patients by 20 months after the initial seizure and in 26 percent of the patients by 36 months after the first seizure, but the recurrence rate was greater in patients with generalized spike-wave EEGs and in patients with siblings who had had seizures. In patients with prior neurologic insult (cerebrovascular accident, meningitis, etc.), the recurrence rate was 34 percent by 20 months after the initial seizure.

Immediate diagnostic evaluation (Table121-3) is initiated in the emergency situation. If the seizure was brief and appears to be idiopathic, the decision to initiate anticonvulsant therapy can be deferred until the appropriate neurologic assessment is completed. The causes of a first seizure vary, but idiopathic seizures account for 26.3 to 47 percent of children seen with seizures, depending on the study cited. Secondary seizures occur for a wide variety of reasons (e.g., inflammatory, structural, metabolic, or secondary to general illness).

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