Febrile seizures in emergency department

Dr.Tarek Sayed

Background• Febrile seizures are the most common type of seizures

observed in the pediatric age group .• Definition :- a febrile seizure is defined as a seizure

associated with febrile illness without a CNS infection or other cause (such as electrolyte imbalance) in a child not known to have epilepsy.

• Another definition from the International League Against Epilepsy (ILAE) is "a seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures".

Incidence :

• About 3 in 100 children have a febrile seizure sometime before their sixth birthday. They most commonly occur between the ages of 18 months and three years. They are rare in children aged under six months and over the age of six years.

Febrile seizures are characterized into two groups: simple febrile seizures and complex febrile seizures. Basically, if the child does not meet the criteria for a simple febrile seizure it is called a complex febrile seizure.

Simple febrile seizures Complex febrile sezures

age 6-60 months < 6 months or>60 months

duration < 15 minutes > 15 minutes

type Generalized tonic clonic Focal

recurrence Non in 24 hours Recurring in 24 hours

Factors associated with increased risk of recurrence :

• Younger age < 18 months.• Family history of febrile seizures.• Low peak temperature.• Shorter duration of fever. The risk of having another febrile seizure

after the first episode is 29-35%.

• Neurodevelopmental abnormality.• Complex febrile seizure.• Family history of epilepsy.• The recurrence of episodes of feb.seizures in

a child does not increase the risk of subsequent epilepsy.

The risk of epilepsy following a simple febrile seizure is 1-2.4% and following a complex febrile seizure is 4.1-6%.

Risk factors of subsequent epilepsy :

Case scenario:• 2 years old child• parents “shaking episode” lasting “10 mins”• EMS called - child no longer shaking.• V/S - BP 105/60 HR 100 RR 18 Sat N T 39• HOW TO APPROACH ?

How to approach a case of febrile seizuresStable patient post sz

• History• Physical examination• Laboratory studies• Imaging• EEG• Treatment• Counseling and family education

History

• 1st focus the initial history on the nature of the seizure: preseiz. – during seiz. – after seiz

• 2ry Focus on the history of fever, duration of fever, and potential exposures to illness.

• A history of the cause of fever (eg, viral illnesses, gastroenteritis) should be elucidated.

• Recent antibiotic use is particularly important because partially treated meningitis must be considered.

• Determine whether there is evidence of possible central nervous system infection

(meningitis or encephalitis)*

Physical examination• The underlying cause for the fever should be sought.• A careful physical examination often reveals otitis

media, pharyngitis, or a viral exanthem. • Although bacterial meningitis is present in a small

minority (2%–5%) of children with apparent febrile seizures, a high level of suspicion is important especially in the young infant.*careful neurological exam. Is a must.

Recommendations for evaluation of simple febrile seizures from the American Academy of Pediatrics and the

International League Against Epilepsy include: • Lumbar puncture is strongly recommended for < 12 months olds, should

be considered in 12-18 month olds. Lumbar puncture is always recommended if there are meningeal signs in patients of any age. Previously antibiotic treatment could mask meningeal signs and lumbar puncture should be strongly considered in those cases.

• EEG is not recommended to be performed for first simple febrile seizure. • Routine electrolytes, calcium, phosphorous, magnesium are not

recommended for first simple febrile seizure unless indicated for other reason such as acute diarrhea that may predispose to electrolyte abnormalities.

• A complete blood count is useful in the evaluation of fever and possible bacteremia particularly in children < 2 years but is not routinely recommended.

• Neuroimaging is not recommended for first simple febrile seizure.

Recommendations for evaluation of complex febrile seizures

from the International League Against Epilepsy include: • Lumbar puncture: Evaluation for a source of possible infection including a

lumbar puncture for any patient with suspected meningeal signs .• Routine chemistry tests are not recommended but should be considered

based upon clinical conditions .• EEG is recommended.• Neuroimaging is highly recommended

Management:• The child with simple febrile seizures rarely needs acute

intervention other than treatment of the underlying illness and fever. Parents need counseling and reassurance.

• When necessary, manage febrile seizures with benzodiazepines. Manage status epilepticus as a medical emergency Consider rectal diazepam in the home setting because it is rapidly absorbed and is safe and effective. Persistent alteration of mental status may require emergency department observation and subsequent hospitalization.

• A child who has a febrile seizure usually doesn't need to be hospitalized. If the seizure is prolonged or is accompanied by a serious infection, or if the source of the infection cannot be determined, a doctor may recommend that the child be hospitalized for observation

Treatment considerations

• ABC’s• Brief directed Hx and Px• Glucose • Antibiotics/Antivirals

– if meningitis/encephalitis considered

SE treatment

• 1st line anticonvulsants– IV

• lorazepam 0.1mg/kg• diazepam 0.2 mg/kg• midazolam 0.2 mg/kg

– rectal diazepam• 2-5 yrs – 0.5 mg/kg• 6-11 yrs – 0.3 mg/kg• >12 yrs – 0.2 mg/kg

– IM, intranasal, buccal midazolam

SE Treatment

• 2nd line agents– phenytoin 20 mg/kg @ 1mg/kg/min

(upto 50 mg/min)– fosphenytoin 15-20 PE/kg @ 3

mg/kg/min (upto 150 mg/min)

• 3rd line agents– phenobarbital 20mg/kg @ 100mg/min– repeat prn 5-10mg/kg– maximum 40 mg/kg or 1 gram

Refractory SE treatment• consider midazolam

– 0.2 mg/kg bolus– then 1-10 mcg/kg/min

infusion• induce barbiturate coma

– pentobarbital 5-15 mg/kg @ 25 mg/min

– then 1-5 mg/kg/hour• others

– valproic acid– paraldehyde, chloral hydrate– propofol, inhalational

anesthesia, paralysis– lidocaine

Patient with febrile seizures

Hitory

Phsical examinatiopn

Consider cultures LP,CBC,CRP,Urine

analysis,U/E

• ASSESS SEVERITY OF ILLNESS

Mild/moderate

severe Very severe

Assess type of seizureIdentify and treat seriuos bactreialInf.,bacteremia,meningitis,pnemoniaUTI/pyelonephritis,bacterial enteritis

simple complex

assess

Treat:Benzodizepine if needed,Educationreasurance

Persistent altered mental status or local signs

no yes

Status epilepticusShockComaResp. failurehypoxia

StabilizeHospitalize in ICU

Considerhospitalization

• Persistent altered mental status or focal signs

No

Discharge and follow up:Contact in 24-48 hMonitor for recurrence and for epilepsy

no recurrence Recurrent febrile seizures Non febrile seizure/epilepsy

TreatConsider prophylaxis with feverHome rectal benzodiazepine Consider AEDS

THANK YOU