Qustion for the Peds MD's re: 1st Seizure...

[TysonCook]

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Quick q from a patient I had last night in the peds ED.

10yo male, no PMHx, very normal childhood, with new onset tonic clonic Sz. Lasted about 7min, witnessed by brother (same bedroom), happened while starting to go to sleep. No bowel/bladder loss, no tongue or other trauma, no etoh, drugs etc. Post ictal around 15 minutes, but NL once at ED. No fever or recent illness, no recent trauma, no hx or fam hx of sz, no meds.

Normal Exam, full nueuro NL etc.
NL metabolic panel, EKG, CXR and CT brain.

Here is my question, the child had just moved from out of state and had no follow up MD to go to. Would you think this child should be admitted for further eval as no PCP? DC'd home with a "call a doctor in the AM"? seen by staff peds (resident service) in house then DC'd home (pt did not qualify as out of county resident)?

Just wondering what you might do when/if consulted with a patient like this?

(on a side, I called a private groups answering service, made sure that they had an opening this AM for new patients and that the pt would be seen today today)

Thanks, I'm just trying to figure out where to draw the "concerned" line for a neg w/u but new onset Sz.

 

[bks524]

My general rule is 1 seizure for everyone. Meaning, anyone can have 1 seizure and not generate some huge workup. A few exceptions to that rule.

1. trauma
2. metabolic abnormality (I check a BMP in a lot of seizures-especially 1st)
3. focal neurologic findings

this is a brief but usually pretty good list. It seems like your patient had a very typical 1st time seizure with a post-ictal phase that was acceptable. I think that it is appropriate to send patients home if they are recovered from the seizure and have normal exam and labs. The point about follow up is very valid, but I don't generally admit if that is the only problem. Usually follow up is not a problem (unless the parents are the reason follow up is a problem). My hospital has a staff pediatrician on call that is there for new patients to follow up with.

 

[ekydrd]

My general rule is 1 seizure for everyone. Meaning, anyone can have 1 seizure and not generate some huge workup. A few exceptions to that rule.

1. trauma
2. metabolic abnormality (I check a BMP in a lot of seizures-especially 1st)
3. focal neurologic findings

...

In this age group you also have to unfortunately think of drugs and alcohol withdrawal as well.

This case brings to mind though, a specific type of seizures that can be seen in this age group. Juvenile myoclonic epilepsy is common and has symptom onset in adolescence through early adulthood. With careful questioning you might elicit complaints of lightning like limb jerks misinterpreted as clumsiness that can be worse with sleep deprivation, stress or poor eating habits. The jerking can devolve into generalized tonic-clonic seizures without treatment. They can also have "drop attacks" upon arising first thing in the morning when they are still sleepy.

 

[TysonCook]

Thank you for your advice. I did ask the standard drugs/etoh with the parents out of the room, as well as home violence. All of which was neg.

Thanks again!
Tys