PEDIATRICS Vol. 111 No. 1 January 2003, pp. 194-196
COMMENTARY |
Less Testing Is Needed in the Emergency Room After a First Afebrile Seizure
Abbreviations: CT, computed tomography • MRI, magnetic resonance imaging • EEG, electroencephalogram • ER, emergency room
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INTRODUCTION |
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 TOP INTRODUCTION EVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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A stereotype of the aftermath of a child’s first afebrile seizure seems to be that the child and the panicked parents are brought to the emergency department by ambulance, an IV in place. Most often the seizure has stopped. Blood work is obtained, a computed tomography (CT) scan is done, and then a history and a physical examination are performed—in that order. A neurologist often is then consulted. This sequence usually is followed by a magnetic resonance imaging (MRI) and an electroencephalogram (EEG) scheduled for the following week, because they are difficult to obtain immediately. The cost of such an evaluation is not trivial (Fig 1), and the benefits are dubious. And yet, such a full-press evaluation seems common.
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Physicians staffing emergency departments are often trained in adult care where tumors and vascular events are far more common causes of initial seizures. The evaluation of a child with a new-onset afebrile seizure is often erroneously extrapolated from the adult protocols. Physicians are afraid of being "less than complete," lest there be subsequent malpractice litigation if everything that could be done is not done. But children are not small adults. The causes of first seizures in children and adolescents, their proper evaluation, their consequences, and their treatment should be different from the adult’s treatment. Seventy percent of seizure disorders start in childhood. Two percent of all emergency department visits to the Boston Children’s Hospital over a 33-month period were for children who had had a seizure. Eighteen percent (500 children) had a first nonfebrile seizure. These 500 children are the subject of the study of the value of emergency neuroimaging in this issue by Sharma, Riviello, Harper, and Baskin.1 The authors have provided us with good information from which to conclude that emergency brain scanning is rarely necessary in children after a first seizure—if you take a history and do a physical examination.
In this important study, 475 of 500 children were imaged in the emergency department. Ninety-two percent had either normal imaging or "insignificant" abnormalities (those that did not change the patient’s management or prognosis). Only 38 of 475 children had "clinically significant" abnormalities, and only 3 of these required acute (immediate) operative intervention, 1 for a blocked shunt that needed to be revised, 1 for measurement of intracranial pressure after closed head trauma. The third had infantile spasms and a tumor.
Children with "clinically significant abnormalities" could be identified from what the authors defined as high-risk groups. These were children with "predisposing factors" such as bleeding or clotting disorders, malignancy, human immunodeficiency virus, or closed head injury, and those with a focal seizure who were younger than 33 months of age.
Even in the high-risk groups, only about one quarter of the children were found to have "clinically significant" abnormalities, and many of those children could have been identified by history or physical examination. Significant findings included prolonged mental status changes after the seizure, or a new hemiparesis. Only 2 children in the low-risk group, 1 with a benign tumor and 1 with a cortical dysplasia, ultimately required operative intervention, and these probably could have been discovered because of subsequent seizures and the MRI done if or when seizures recurred.
The Quality Standards Subcommittee of the American Academy of Neurology, the Child Neurology Society, and the American Epilepsy Society,2 after reviewing the published literature, has written that after a first unprovoked nonfebrile seizure in a child or adolescent there is insufficient evidence to support a recommendation to routinely perform a lumbar puncture, laboratory studies, or routine neuroimaging. The subcommittee concluded that emergency imaging could be reserved for the very small group of children with new-onset neurologic deficit or long-lasting changes in mental status. MRI, which often requires sedation in small children, could be performed on a nonemergency basis for delineation of specific epilepsy syndromes.
The current study by Sharma et al1 provides strong support for those conclusions and complements the study by Berg et al.3 All of these studies recommend that well-appearing children who are not in high-risk categories may be discharged safely from the emergency department without emergency scanning.
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EVALUATION OF A FIRST AFEBRILE SEIZURE |
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What then should be the evaluation and management of a child who presents to the emergency department after a first afebrile seizure?
- The child must be examined immediately to assure that he or she is not continuing to seize, and has adequate oxygenation and stable vital signs.
- A history should be taken to ascertain that a seizure did occur, that it was the first seizure, and that there were no provoking factors such as head trauma. Additional history may reveal the circumstances and characteristics of the seizure: the time of day or night that it occurred, the presence of flashing lights, preceding myoclonic jerks, a focal onset, or other indicators suggesting specific epilepsy syndromes.
- A screening physical examination should be performed looking for evidence of alteration in mental status, or the presence of a new neurologic deficit.
- Unless there are special circumstances, blood work, a lumbar puncture, EEG, and neuroimaging are not needed in the emergency department.
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MANAGEMENT AFTER A FIRST AFEBRILE SEIZURE |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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"Is that all you are going to do," the parents will ask. "Aren’t you going to do any tests?"
The most important aspect of management after a first afebrile seizure is a thorough discussion with the parents and older patients. The discussion should include the following:
- What a seizure is, and what it is not. What does or does not happen to the child and the child’s brain during a seizure.
- What activities the child may or may not do now that he or she has had a seizure.
- The likelihood of a recurrence, and what to do if the child has another seizure.
Ideally, this discussion should take place before the child is discharged from the emergency department, but that is unlikely to happen. More realistically, a discussion should take place in the child’s physician’s office within a few days of the seizure.
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THE NONEMERGENT EVALUATION |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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An MRI?
Children who have had a focal seizure and are under 33 months of age should have an MRI scan with sedation, but this need not be done not urgently. Only 23 of the 475 children in Sharma’s study had "clinically significant" abnormalities, and only 3 of these required acute surgical intervention. The cost of MRIs for all 500 children in the study would have been in the range of $500000 in order to uncover 1 child with head trauma who needed intracranial pressure and a second with hydrocephalus who needed his shunt revised. Both of these children should have been identified and scanned on the basis of their prior history. Is this a good use of expensive resources?
Using appropriate judgment, laboratory testing and a CT usually need not be done in the emergency room (ER). Neurologic consultation is rarely needed.
An EEG?
The Quality Standards Subcommittee2 found that there was sufficient evidence that an "EEG done after a first nonfebrile seizure can be useful in predicting the risk of recurrence; can be useful in differentiating a seizure from other events; can diagnose certain epileptic syndromes; and can provide information on the child’s long-term prognosis." The subcommittee further states, "The EEG may influence the need for subsequent neuroimaging studies and may influence counseling regarding management of the child." The subcommittee therefore recommended that an EEG be done as part of the neurodiagnostic evaluation of a child with an apparent first unprovoked seizure, although it does not influence the decision regarding treatment after a first seizure.4
The author of this commentary continues to disagree with this recommendation,5 which seems to have considerable financial and legal implications and only limited usefulness. The costs of an EEG is $330, and the total for these 500 children would have been $165000. This expenditure enables the physician to differentiate children who have a 25% chance of recurrence from those that have a 75% chance of recurrence. Because even the subcommittee6 does not recommend therapy after a first afebrile seizure, is the information worth the price? Only rarely does the EEG affect the decision to treat.
If an EEG is done after a first seizure, when should it be done? After a generalized tonic-clonic seizure, the EEG is often slow, and the duration of the slowing is often proportional to the duration of the seizure. This slowing may obscure subtle, focal changes. If a routine EEG is done, it should be scheduled sometime in the few weeks after the seizure. After all, you are just trying to find if there is an epilepsy syndrome present; if there is focality requiring an MRI; and the likelihood of recurrence.
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TREATMENT AFTER A FIRST NONFEBRILE SEIZURE |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society recently reviewed the literature regarding the risks associated with a first unprovoked seizure in a child or adolescent, as well as the risks and benefits associated with anticonvulsant therapy.6 In an excellent analysis of the risks of treatment and of nontreatment, the Committee concluded that although anticonvulsant medication may decrease the risk of a second seizure, it does not decrease the long-term risk of subsequent epilepsy. They noted that anti-epileptic drugs have clinically relevant cognitive and behavioral effects. Their recommendation was that the decision whether or not to treat with anti-epileptic drugs after a first unprovoked seizure should be individualized based on the medical issues and family preference.
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MANAGEMENT OF FIRST SEIZURES |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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Parents usually want to know why the seizure occurred. "Why did my child have this frightening thing?"
There are 7 general categories of causes for seizures, and they usually can be sorted out by the history and physical examination:
- Head trauma: Readily distinguished by history and physical examination.
- Infection (meningitis, encephalitis): Usually distinguishable by the child’s recent history, by the presence of fever, and by the child’s mental status.
- Metabolic or degenerative disease: Distinguishable by the child’s developmental history and physical examination.
- Vascular problems (such as bleeding or thrombosis): Distinguishable by history and the presence of acute neurologic deficit.
- Brain tumors: A very rare cause of first seizures and usually associated with other neurologic signs.
- Developmental problems and dysplasias of the brain: Often associated with cerebral palsy or developmental delay and distinguishable by the developmental history and physical examination, or the occurrence of recurrent focal seizures.
- Idiopathic (I don’t know why it occurred): Idiopathic seizures account for 70% of afebrile seizures. They are the type most likely to occur in otherwise healthy children and are the most likely not to recur. If they recur (epilepsy), they are most likely to come under control with anticonvulsant medication, and most likely to be outgrown. "Idiopathic" is the most common cause in otherwise normal children and far preferable to the other causes.
When framed in this fashion, most parents would prefer that their child had an idiopathic seizure, a seizure of unknown cause.
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CONCLUSION |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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The study by Sharma et al in this issue reaffirms the conclusion that the emergency department evaluation of most children who have had a first unprovoked seizure requires only a careful history and physical examination, and little laboratory testing. Imaging studies should be done only in selected cases. The current costs of evaluation exceed $3000 per child. The cost of an appropriate ER evaluation which would include a history, a physical examination, observation, and a discussion with the family could reduce the cost of most basic evaluations to $800. The CT would be done rarely, the MRI only appropriately, and an EEG done sometimes. The potential cost savings of this more rational approach, multiplied by the large number of children who have initial nonfebrile seizures, could be huge. If we modified the workup of children who returned to the ER with recurrent seizures, the savings could be even larger.
Most children need not be started on anticonvulsant medication after a first nonfebrile seizure. A thorough discussion of the meaning and implications of the seizure may be the most important part of the treatment.
Johns Hopkins Medical Institutions
Baltimore, MD 21247-7247
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FOOTNOTES
Received for publication Aug 14, 2002; Accepted Aug 14, 2002.
Address correspondence to John M. Freeman, MD, Meyer 2–147, Johns Hopkins Medical Institutions, Baltimore, MD 21287-7247. E-mail: jfreeman{at}jhmi.edu
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REFERENCES |
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TOPINTRODUCTIONEVALUATION OF A FIRST...MANAGEMENT AFTER A FIRST...THE NONEMERGENT EVALUATIONTREATMENT AFTER A FIRST...MANAGEMENT OF FIRST SEIZURESCONCLUSIONREFERENCES |
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- Sharma S, Riviello JJ, Harper MB, Baskin MN. The role of emergent neuroimaging in children with new-onset afebrile seizures.
Pediatrics.2003; 111
:1
–5
[Abstract/Free Full Text] - 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
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–623
[Abstract/Free Full Text] - Berg AT, Testa FM, Levy SR, Shinnar S. Neuroimaging in children with newly diagnosed epilepsy: a community based study.
Pediatrics.2000; 106
:527
–532
[Abstract/Free Full Text] - Hirtz D, Ashwal S, Berg A, et al. Practice parameter: evaluating a first non-febrile seizure in children: report of the Quality Standards Committee of the American Academy of Neurology, the Child Neurology and the American Epilepsy Society [reply].
Neurology.2001; 56
:574
[Free Full Text] - Freeman J. Practice parameter: evaluating a first non-febrile seizure in children: report of the Quality Standards Committee of the American Academy of Neurology, the Child Neurology and the American Epilepsy Society [letter]. Neurology.2001; 56 :574
- Hirtz D, Berg A, Bettis D, et al. Practice parameter: treatment of the child with a first unprovoked seizure. Neurology. 2003. In press
PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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