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Febrile Seizure

Dec 03, 20246 min read

Characteristics

  • Caused by the increase in the core body temperature more than 38°C. (the maximum height of a fever, rather than the rate of rise).

  • The threshold of temperature which triggers seizures is unique to each individual, lower in infants and is modified by certain medications/water and electrolyte imbalances.

  • Seizure accompanied by fever.

  • Most often occur within 24 hours of the onset of a fever.

  • Febrile Seizure can be the first sign of illness in 25-50% of patients.

  • Children presenting with a first-time febrile seizure have a 30% chance of having another febrile seizure during early childhood.

  • Are benign / .(2 - 5% of children ),

  • Occurrence: between 6 months to 5 years of age , Peak 12 - 18 months.Z

  • Febrile seizures are a common cause of convulsions in young children

  • Majority (65- 90%) of these are simple febrile seizure

  • Seizure accompanied by fever without any :

    • Central nervous system infection
    • Metabolic disturbance
    • History of previous seizure disorder

Risk Factors

  • Viral infections:

    • Human herpesvirus 6 (HHV-6) is commonly associated.

  • Administration of certain vaccines:

    • Diphtheria, tetanus toxoid, and whole-cell pertussis (DTwP);
    • Measles, mumps, and rubella (MMR).

  • Susceptibility to febrile seizures

    • has been linked to several genetic loci in different families (AD). #Z (autosomal recessive)

  • Prenatal exposure

    • to nicotine,
    • iron deficiency,
    • atopic diseases.

Types

Simple Febrile

  • Seizure lasts less than 15 minutes.
  • Generalized seizure.
  • Occurs once in a 24-hour period.
  • No previous neurologic problems.

Complex Febrile - One or more of following

  • Prolonged (lasts more than 15 minutes)
  • Focal seizure
  • Occurs more than once in 24 hours.
  • Postictal paresis
  • Patient has known neurologic problems,
    • e.g., developmental delay

Risk Factors for Later Epilepsy

  • Complex febrile seizure

  • Family history of epilepsy

  • Neurodevelopmental abnormality (e.g., cerebral palsy, hydrocephalus)

  • Ethnicity, sex, family history of febrile seizures, age at first febrile seizure, and height of fever are not risk factors for the subsequent development of epilepsy.

  • 5-10% of children with complex febrile seizures subsequently developed an afebrile seizure disorder (1-2% in simple febrile seizures).

Febrile Seizure: ED Assessment

Baseline Assessment

  • Vital signs (antipyretic if high temp).

  • Assess neurological status (AVPU).

  • Assess the A, B, C, Ds

  • Continue documenting seizure and providing aspiration precautions.

  • Febrile seizures that continue for more than five minutes should be treated. Intravenous benzodiazepines or lorazepam are effective in aborting seizure in many cases. Buccal midazolam is an effective alternative. Intranasal lorazepam is also an option.

  • The child’s respiratory and circulatory status should be monitored carefully (respiratory depression).

Physical Exam

  • Check blood glucose
  • If blood glucose < 60 mg/dL, treat as appropriate

Full History

  • Obtain seizure history from a dependable witness:

    • When did the seizure occur?
    • How long was the seizure and what did it look like?
    • How was the child acting immediately before the seizure?
    • History of previous seizures (child and family)?
    • History of developmental delay/recent loss of milestones?
    • Does the child have a current illness/fever/daycare attendance?
    • Any indications of trauma or abuse?
    • Length of postictal state?
    • Immunization history?
    • Presence of chronic illness?

  • List current medications

    • Include any antipyretics given (time and dose)/recent antibiotic therapy.

Simple Febrile Seizure: ED Ongoing Management

  • Reassess temp and consider giving antipyretic if not previously administered.

  • As the source of fever is identified, treat appropriately.

  • If still having a seizure, follow Status Epilepticus protocol (Phenytoin).

Febrile Seizure: ED Management

  • Complete physical exam – to identify the source of fever

  • Lab testing – direct toward identifying the source of fever (As the source of fever is identified, treat appropriately).

    • A complete blood count and measurement of serum electrolytes, blood sugar, calcium, and urea nitrogen.
    • If a decision to perform an LP has been made, blood culture and serum glucose testing should be performed concurrently.

  • Neuroimaging (CT/MRI):

    • History or examination suggestive of trauma, or a possible structural defect (e.g., microcephaly or spasticity), Focal seizures.

Lumbar Puncture Indication

  • When there are meningeal signs or symptoms or other clinical features that suggest possible meningitis/encephalitis.
  • Infants between 6-12 months of age, if the immunization status for Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae is deficient or undetermined.
  • Current treatment with antibiotics (antibiotics can mask the signs and symptoms of meningitis).
  • Febrile status epilepticus (FSE)
  • Seizures that occur after the second day of a febrile illness/Focal

Simple Febrile Seizure: Diagnostic Testing

  • EEG: Should not be performed in a neurologically healthy child. Results are not predictive of recurrence or development of epilepsy.
  • CT/MRI: Not indicated

The American Academy of Pediatrics’ guidelines recommend neuroimaging should not be performed as part of a routine evaluation of a child with a simple febrile seizure.  If the child has a complex febrile seizure, an EEG and CT or MRI can be helpful, but this can be performed as an outpatient.

Long Term Management

  • Current guidelines do not recommend the use of continuous or intermittent therapy with phenobarbital or benzodiazepines after a simple febrile seizure.
  • No medication reduces the risk of afebrile seizure after a simple febrile seizure.

Simple Febrile Seizure: Family Education

Frequently Asked Questions

  • Is my child brain damaged?
    • There is no evidence of impact on learning abilities after a seizure from SFS.
  • Will this happen again?
    • If the child is under 12 months of age at the time of the first seizure, the recurrence rate is 50%.
    • If the child is greater than 12 months of age at the time of the first seizure, the recurrence rate is 20%.
    • Most recurrences (50-75%) occur within 12 months of the initial febrile seizure.

Will my child get epilepsy?

  • For simple febrile seizures, there is no increased risk of epilepsy.

Why not treat for possible seizures or fever?

  • Anticonvulsants can reduce recurrence. However, potential side effects of medications outweigh the minor risk of recurrence.
  • Prophylactic use of antipyretics does not have an impact on recurrence.
  • For complex febrile seizures, there is a slight increase in the risk of epilepsy.

Instruct Parent/Caregivers to Prevent Injury During a Seizure

  • Position child while seizing in a side-lying position
  • Protect head from injury
  • Loosen tight clothing about the neck
  • Prevent injury from falls
  • Reassure child during the event
  • Do not place anything in the child’s mouth
  • Rectal Diazepam, Given for seizures lasting longer than 5 minutes.

Simple Febrile Seizure: Disposition

Prior to Discharge Home

  • Educate regarding the use of: - Thermometer - Antipyretics for fever management - When to contact 9-1-1 or ambulance 997 - Call after 5 minutes of seizure activity

  • Identify a Primary Care Provider for follow-up appointment and stress the importance of follow-up

  • Provide a developmentally appropriate explanation of the event for the child and family members.

  • Provide family with rectal Diazepam

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