Management of a First Non-febrile Convulsive Seizure in the Pediatric Emergency Department: A Retrospective Study From 2015 to 2021 at the University Hospital of Reims

Introduction: The onset of epileptic manifestations frequently occurs during childhood and often leads to initial management in pediatric emergency departments. The diagnostic approach is challenging, as epileptic seizures must be distinguished from non-epileptic paroxysmal events and acute symptomatic seizures. Although several national and international recommendations exist, real-world data on the management of first seizures in pediatric emergency settings remain limited. Objective: The primary objective of this study was to analyze patient characteristics and management of children presenting to a pediatric emergency department with a first non-febrile convulsive seizure. The secondary objective was to develop a practical management algorithm tailored to pediatric emergency settings. Methods: We conducted a retrospective, single-center observational study in a tertiary pediatric hospital in Reims, France. All patients under 18 years of age presenting to the pediatric emergency department with a first non-febrile convulsive seizure between January 1, 2015, and June 30, 2021, were included. Results: Data from 167 children were analyzed and categorized into three groups: epileptic seizure (99, 59.3%), non-epileptic paroxysmal event (64, 38.3%), and acute symptomatic seizure (4, 2.4%). Clinical examination was normal in the majority of cases and did not reliably discriminate between groups. Semiological features such as eye deviation, eye rolling, generalized or focal hypertonia, and postictal confusion were significantly associated with epileptic seizures, whereas stressful or vasovagal situations were more frequent in non-epileptic events. All patients in the epileptic group underwent neuropediatric consultation, and 55 (55.5%) were discharged with antiepileptic treatment. Laboratory investigations were performed in 52 (52.5%) patients, with abnormalities identified in only 4% of cases. Electroencephalography (EEG) was performed in 96 (96.7%) patients and showed abnormalities in 64 (69.8%). In non-epileptic events, the EEG was normal in all cases where it was performed. Brain imaging was selectively performed and identified structural abnormalities in 21 (26.6%) patients who underwent MRI. Conclusions: In children presenting with a first non-febrile convulsive event, epileptic seizures accounted for a substantial proportion of cases, while non-epileptic events remained frequent. Clinical history and witness description were the most informative elements for diagnosis, whereas routine laboratory testing had limited utility. EEG and neuroimaging were valuable in selected cases. The proposed management algorithm provides a pragmatic, emergency-oriented framework to support clinical decision-making and help standardize the evaluation of these patients.