Seizure - First presentation


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.


To guide PCH ED staff with the assessment and management of a first seizure. presentation.


  • A seizure is the physical and behavioural changes that occur after an episode of abnormal activity in the brain or part of the brain.
  • It is a symptom not a diagnosis.


  • By the age of 16 years, approximately 1% of the population will have suffered a seizure without a fever.1,2,3
  • Recurrence risk:2,3
    • 25% will have a second afebrile seizure in the next year
    • 45% will have a second afebrile seizure in the next 14 years
      •  75% of those will have a third afebrile seizure
      • 88% of those are within two years.



General history including:

  • fever
  • headache and/or photophobia 
  • neurological state and behaviour prior to seizure
  • duration of seizure, focal features
  • recent trauma
  • poisons / drug ingestion
  • co-morbidities e.g. ventriculoperitoneal (VP) shunt
  • developmental history
  • determine if the child has had a vaccination in the past 14 days. If so, a WAVSS WA Vaccine Safety Surveillance: Adverse Reaction Reporting Form needs to be completed.


  • Systems examination including full neurological examination
  • Assess for meningism


  • Glucose
  • UEC, Calcium, Magnesium, Phosphate
  • CT if clinically indicated (seek Emergency Department Senior Doctor advice)
  • ECG
  • EEG to be arranged by General Paediatric Team if appropriate when outpatient referral received 
  • Metabolic screen if clinically indicated.

Differential diagnoses

  • Febrile convulsion
  • Meningoencephalitis
  • Breath holding
  • Syncope
  • Gastro-oesophageal reflux (GOR)
  • Arrhythmias
  • Stroke
  • Panic attack
  • Migraine
  • Psychosis
  • Pseudo seizures


  • Most seizures will self-terminate within 5 minutes. Those that last longer are likely to require treatment to terminate.
  • If a seizure is still in progress on arrival to the Emergency Department, treatment should commence as per ED Guideline: Status epilepticus.

Admission criteria

  • Prolonged seizure > 15 minutes
  • GCS < 15 (1 hour post seizure)
  • Atypical febrile convulsion
  • Age < 1 year
  • > 1 seizure
  • Focal seizures
  • Signs of raised intracranial pressure (ICP)
  • Meningoencephalitis
  • Signs of aspiration
  • Non accidental injury (NAI)
  • High parental / carer anxiety

Discharge criteria

  • Parents should be warned that all children or adolescents who have had seizures should be supervised when bathing, swimming, riding a bicycle on the road, and should avoid tree climbing.
  • Parents should be advised of first aid measures and given parent information sheet - First Aid for Seizures.
  • Arrange referral to General Paediatric Clinic.

Management of first seizure flowchart. Click to enlarge.


  1. Hirtz D, Berg A, Bettis D, Camfield C, Camfield P et al; Practice Parameter: Treatment of the Child with a First Unprovoked Seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Quality Standards Subcommittee of the American Academy of Neurology, Practice Committee of the Child Neurology Society Neurology. 2003;60(2):166. 
  2. Arthur TM, deGrauw TJ, Johnson CS, Perkins SM, Kalnin A, et al; Seizure recurrence risk following a first seizure in neurologically normal children. Epilepsia. 2008; 49(11):1950. 
  3. Shinnar S, Berg AT, MoshéSL, Petix M, Maytal J, Kang H, Goldensohn ES, Hauser. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics. 1990;85(6):1076-85. 

Endorsed by: CPAC  Date:  May 2020

 Review date:   May 2023

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