Febrile SeizuresBy Hasan Ismail

Case presentation

ER : one of your patients is being evaluated for new-onset seizures.

The 2-year-old boy was in his normal state of good health until this

morning, when he complained of a headache and then fell to the floor.

While waiting for the ED physician to come to the phone. According to

the ED physician, the boy’s mother saw jerking of both arms and legs.

When the ambulance arrived 5 minutes later, the child had stopped

jerking but was not arousable

; his heart rate was 108 bpm, respiratory rate 16 breaths/min, blood

pressure 90/60 mm Hg, and temperature 104°F (40°C). His blood sugar

level was 135 mg/dL. By the time the child arrived to the ED, he was

awake and he recognized his parents. His physical examination in the

ED is normal, as are his complete blood count and urinalysis.

Types

• SFC:

- infection. CNS ?

- Unrecognized epilepsy

- T.C.

• Complex AFS

- Focal

- Timing

- recurrence

Prognosis

• SFC : excellent, no intellectual defects

(70-80%)

• Atypical : cause ?

(20-30%)

What to do ?!

• Relax

• Recovery Position

• Hospital if > 5 mins

• 4-8 % of children

• Usually between 6 months and 6 years

• Average of 18 months

Stop Ongoing Seizure By:

- Diazepam : 0,2 mg/Kg IV, or

0,5 mg/Kg Rec.

- Midazolam : IV, 0,2 mg/Kg max : 5mg.

Buccal : 0,4 - 0,5 mg/Kg

Intranasal : 0,2 mg|Kg/dose

- Lorazepam: 0.05 - 0.1 MG/ KG/ dose

MAJOR RF for Recurrence

1- Onset of FS < 1 Year of age

2- Duration of fever < 24 hr

3- Fever 38-39

Indication for LP

• < 6 Mo

• Seizure occurring after 3 days of fever.

• Prolonged postictal phase.

• Complex (FS).

• No cause of fever.

• Anorexia.

Back to Case presentation

ER : one of your patients is being evaluated for new-onset seizures.

The 2-year-old boy was in his normal state of good health until this

morning, when he complained of a headache and then fell to the floor.

While waiting for the ED physician to come to the phone. According to

the ED physician, the boy’s mother saw jerking of both arms and legs.

When the ambulance arrived 5 minutes later, the child had stopped

jerking but was not arousable

; his heart rate was 108 bpm, respiratory rate 16 breaths/min, blood

pressure 90/60 mm Hg, and temperature 104°F (40°C). His blood sugar

level was 135 mg/dL. By the time the child arrived to the ED, he was

awake and he recognized his parents. His physical examination in the

ED is normal, as are his complete blood count and urinalysis.

➤ Questions ?

➤ Diagnosis?

➤ Best management for this condition?

➤ Course and prognosis ?

1) Paramedics bring to the ED a 7-month-old infant with seizure activity.

The father reports the infant was in a normal state of health until

approximately 3 days ago when she developed a febrile illness, diagnosed

by her physician as a viral upper respiratory tract infection.

Approximately 30 minutes ago she began having left arm jerking, which

progressed to whole-body jerking. The episode spontaneously ceased on

the way to the hospital. Vital signs include heart rate 90 bpm, respiratory

rate 25 breaths/min, and temperature 100.4°F (38°C). Your examination

reveals a sleeping infant in no respiratory distress. The child’s

anterior fontanelle is full. The oropharynx is clear, and crusted mucous

is found in the nares. The tympanic membranes are dark and without

normal landmarks. The lungs are clear, and the heart and abdominal

examinations are normal. She has a bruise over the occiput and several

parallel bruises along the spine. Which of the following is the best next

step in management?

A. Computerized tomography (CT) of the head

B. Electroencephalogram

C. Lumbar puncture

D. Observation

E. Phenobarbital

2) A 2-year-old boy who had a simple brief febrile seizure comes to your office 1 day after his ED visit. He is currently afebrile, is happily pulling the sphygmomanometer off the wall, and is taking antibiotics for an ear infection diagnosed the previous day. His mother wants to know what to expect in the future regarding his neurologic status. You correctly tell her which of the following?

A. He has no risk of further seizures because he was age 2 years at the time of his first febrile seizure.

B. He will need to take anticonvulsant medications for 6 to 12 months to prevent further seizure activity.

C. You want to schedule an EEG and a magnetic resonance scan of his head.

D. Although he does have a risk of future febrile convulsions, seizures of his type are generally benign and he is likely to outgrow them.

E. This is an isolated disorder, and his children will not have seizures

3) A 10-month-old boy presents to the ED with a 1-day history of fever to 104°F (40°C), increased irritability, decreased breast-feeding, and refusal of solid foods. The parents brought him in after two 30-second

episodes of generalized jerking that occurred over a 20-minute span. Your examination reveals an awake but lethargic infant. The anterior fontanelle is flat, the tympanic membranes and oropharynx are moist

and not erythematous, the lungs are clear, and the heart and abdominal examinations are normal. He has no focal neurologic findings. Which of the following is the best next step in management?

A. Intravenous ceftriaxone

B. Admission overnight for observation

C. Computerized tomography of the head

D. Discharge from ED to follow up with his primary care provider in 24 hours

E. Lumbar puncture

The father of a 4-year-old girl calls your office to report her second febrile seizure. He states that this seizure was identical to the first one that happened 4 months ago: she developed an elevated temperature and within a short time had a generalized convulsion lasting 90 seconds.

She was sleepy for approximately 2 minutes afterward. Upon awaking, she was given ibuprofen. She is now running around the house, chasing her younger brother and the family’s chihuahua. The parents wonder if she needs to take anticonvulsants now that she has had another seizure. You should tell the father which of the following?

A. Febrile seizures frequently are recurrent but usually have no significant long-term effect.

B. You will prescribe an anticonvulsant because it will reduce the risk of future epilepsy.

C. You will order an EEG and CT scan of her head to be done on an outpatient basis.

D. He needs to take his daughter to the hospital for inpatient admission.

E. He should stop the ibuprofen and observe the fever curve.

➤ Febrile seizures usually are benign and self-limited.They do not require an

extensive diagnostic evaluation unless they are prolonged or focal.

➤ A diagnosis of febrile seizure must be made only after considering the possibility

of central nervous system infection as the seizure cause.

➤ Febrile seizures rarely lead to epilepsy; risk factors for nonfebrile seizures

include preexisting developmental abnormalities and complex febrile

seizures.