Question 19

Outline the principles of initial assessment and management of an 8-year-old child having their first generalized seizure.

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College answer

Most candidates gave good answers and used an appropriate structure. Those candidates who did not gain good marks, gave answers which lacked pertinent details, especially around control of seizures in Paediatrics patients. 


What would have been an "appropriate structure"  here, which 82.7% of the candidates apparently knew? The stem gives no context other than"an 8-year-old child having their first generalized seizure", which makes you think that, when it asks for initial assessment and management, only the most generic responses were required. Also,  the use of the word "having" suggests "they are having it right now in front of you". Thus:

  • Resuscitation
    • Administer oxygen
    • Secure the airway if it is unprotected
    • Achieve IV access, collect a routine panel of blood samples including blood cultures,  and administer IV benzodiazepines
  • Assessment
    • History from parents
      • Provoking factors (medications, toxins, metabolic factors eg. diabetes and DKA, recent illness)
      • Predisposing factors (eg. brain injury)
      • Behaviour immediately prior to the event (eg. aura)
    • Examination findings
      • Seizure vs. other causes of decreased level of consciousness with rigidity or abnormal movements (eg. cardiac event such as arrhythmia, followed by syncope)
      • Focal neurological signs pointing to intracranial pathology
      • Features of sepsis (eg. febrile convulsion)
      • Meningism 
      • Features suggestive of non-convulsive status (eg. dilated pupils, rigidity, clonus)
      • Systemic features suggestive of autoimmune disease or vasculitis
      • General examination/inspection findings suggestive of congenital abnormalities
  • Investigations
    • Biochemistry
      • Normal bloods (BSL/FBC/EUC/CMP/LFT/coags) as well as ammonia level, and serum 
    • Electrophysiology
      • EEG, including awake and sleeping
    • Imaging
      • CT brain (ideally also involving contrast)
      • Lumbar puncture 
      • MRI brain
  • Medium-term management
    • Antiepileptic agents (from Pohlmann-Eden et al, 2006):
      • Initially, and while being worked up: benzodiazepines
      • For focal seizures—carbamazepine, clobazam (especially children), gabapentin, lamotrigine, oxcarbazepine, topiramate, valproate x
      • For generalised seizures—Levitiracetam, lamotrigine, topiramate, valproate.
    • Parents: counselling, specifically re. implications of epilepsy (if this is in fact the diagnosis) and regarding the likelihood of recurrence


Chelse, A. B., et al. "Initial evaluation and management of a first seizure in children." Pediatric Annals 42.12 (2013): e253-e257.

Pohlmann-Eden, Bernd, et al. "The first seizure and its management in adults and children." Bmj 332.7537 (2006): 339-342.