Febrile seizure: Difference between revisions

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==Background==
== Background ==
Criteria:  Seizure + temp >38 in pt age 6 mo - 6 yr without previous afebrile seizure  
*Occurs in 2-5%
*50% of pts <12 mo will have another simple febrile seizure
*30% of pts >12 mo will have another simple febrile seizure


===Simple versus Vomplex===
=== Simple versus Complex ===
# Simple  
#Simple
##Generalized tonic-clonic seizure
##<15 min in duration
##<15 min in duration
## No focal features
##Fever ≥100.4
## Only a single episode in 24 hours
##Age 6mo - 6yr
# Complex
##Occurs only once in 24hr period
## Any exception to above  
##No focal features
#Complex
##Any exception to above


===Risk Factors===
==DDx==
# Family history (2-4x higher)
#Meningitis
# Infection (viral and bacterial)
##More likely if status epilepticus
# Recent vaccinations
#Seizure due to identifiable cause (e.g. intracranial mass, trauma)
# Recurrence
#Epidural/subdural infection or hematoma


==Diagnosis/Work-Up==
==Work-Up ==
# Consider trauma, toxidromes, infection/ petechiae
#Glucose in all pts
# Glucose check
#AAP Guidelines
# if sz >5 min tx with IM, IV, IN Versed 
##Simple febrile seizure
# Consider trauma or toxic cause
###No labs, neuroimaging, or EEG is necessary
# Classifly as simple or comple
##Complex febrile seizure
# Search for devel delay, fam hx,
###Consider CBC, blood cx, UA, Ucx, CSF studies
# Physical exam should focus on source of fever
#Consider CT if:
# Routine lab tests other than blood glucose not needed unless searching for cause of fever (UA, CBC, CXR, etc)
##Persistently abnormal neuro exam (esp w/ focality)
#Consider LP if:
##Signs/symptoms of increased ICP
## Age <12 mo (AAP guidelines)
##pt has VP shunt
### However, bacterial meningitis is rarely the diagnosis if it not clinically suspected
## Seizure occurs after the second day of illness
##Concern for CNS infection
## Febrile status epilepticus
## Pmd visit w/ in 48 hrs
## Sz in ED
## Focal sz
## Abnormal neuro/ phys exam
## Irritable, poor feeding
## Complex features
## Slow postictal clearance
## Pretreated with abx (consider partially tx meningitis if already on abx)
#CT if:  
## Persistently abnormal neuro exam (especially with focal features)
## Signs/symptoms of increased ICP
## Consider for presence of VP shunt
#Routine EEG not indicated
#Routine EEG not indicated
## Consider only if developmental delay or for focal symptoms
##Consider only if developmental delay or for focal symptoms


==DDx==
== Treatment ==
# Meningitis
#Treat if initial seizure persists >5 min or for subsequent seizures
## More likely in patients with status epilepticus
##Benzodiapazines
# Seizure due to identifiable cause (e.g. intracranial mass, trauma)
###Lorazepam (0.05 - 0.1mg/kg)
# Epidural/subdural infection or hematoma
####If seizure persists try one additional dose (risk of resp. depression incr if >2 doses)
####Effective duration of action is up to 4-6 hours
==Treatment==
###Midazolam (0.1-0.3mg/kg)
# Treat if initial seizure persists >5 min or for subsequent seizures
###Diazepam
## Benzodiapazines
####Compared to lorazepam, less effective and more respiratory depression
### Lorazepam (0.05 - 0.1mg/kg)
##Fosphenytoin (15-20 mg/kg)
#### If seizure persists try one additional dose (risk of resp. depression incr if >2 doses)
###Treat if seizure persists despite benzo tx
#### Effective duration of action is up to 4-6 hours  
###Onset of action may take as long as 30 minutes
### Midazolam (0.1-0.3mg/kg)
###Can cause hypotension and dysrhythmias
### Diazepam
##Barbituates
#### Compared to lorazepam, less effective and more respiratory depression  
###Consider only if benzos and phenytoin have failed
## Fosphenytoin (15-20 mg/kg)
###May lead to respiratory depression, especially when preceded by a benzo
### Treat if seizure persists despite benzo tx
##Valproic acid
### Onset of action may take as long as 30 minutes
###Has been shown to be effective when benzos, phenytoin, and barbituates have failed
### Can cause hypotension and dysrhythmias
###Can be used as 2nd or 3rd-line treatment
## Barbituates
##Propofol
### Consider only if benzos and phenytoin have failed  
#Treat underlying infection
### May lead to respiratory depression, especially when preceded by a benzo  
## Valproic acid
### Has been shown to be effective when benzos, phenytoin, and barbituates have failed  
### Can be used as 2nd or 3rd-line treatment  
## Propofol  
# Treat underlying infection
==Disposition==
* Home:  Simple febrile seizure and patient back at baseline with follow up in 1-2 days
* Admit: Complex febrile seizures, lethargy beyond postictal period, uncertain home situation


==Prognosis==
== Disposition ==
Risk of recurrence:
*Discharge
* Majority of recurrences occur within 1st year; almost all occur within 2 years
**Simple febrile seizure if pt at baseline, f/u w/in 1-2d
** If first seizure occurs in age <1yr  = 50%
**Complex febrile seizure if pt well-appearing, labs normal, f/u in 24hr
**If first seizure occurs in age 1-3yr = 25%
*Admit:
** If first seizure occurs in age >3yr = 12%
**Ill-appearing
**Lethargy beyond postictal period


Risk factors for recurrence include:
# Young age at onset
# Family history of febrile seizures
# Low-degree of fever in the ED
# Brief duration between onset of fever and initial seizure
# Complex febrile seizure does not increase risk of recurrent seizures


==See Also==
== See Also ==
Seizure (Peds)
[[Seizure (Peds)]]


Fever (Peds)
[[Fever (Peds)]]


==Source==
== Source ==
Adapted from Gausche, Mistry, Donaldson, Pani, UpToDate
Tintinalli


[[Category:Peds]]
[Category:Peds]]

Revision as of 22:20, 25 June 2011

Background

  • Occurs in 2-5%
  • 50% of pts <12 mo will have another simple febrile seizure
  • 30% of pts >12 mo will have another simple febrile seizure

Simple versus Complex

  1. Simple
    1. Generalized tonic-clonic seizure
    2. <15 min in duration
    3. Fever ≥100.4
    4. Age 6mo - 6yr
    5. Occurs only once in 24hr period
    6. No focal features
  2. Complex
    1. Any exception to above

DDx

  1. Meningitis
    1. More likely if status epilepticus
  2. Seizure due to identifiable cause (e.g. intracranial mass, trauma)
  3. Epidural/subdural infection or hematoma

Work-Up

  1. Glucose in all pts
  2. AAP Guidelines
    1. Simple febrile seizure
      1. No labs, neuroimaging, or EEG is necessary
    2. Complex febrile seizure
      1. Consider CBC, blood cx, UA, Ucx, CSF studies
  3. Consider CT if:
    1. Persistently abnormal neuro exam (esp w/ focality)
    2. Signs/symptoms of increased ICP
    3. pt has VP shunt
  4. Routine EEG not indicated
    1. Consider only if developmental delay or for focal symptoms

Treatment

  1. Treat if initial seizure persists >5 min or for subsequent seizures
    1. Benzodiapazines
      1. Lorazepam (0.05 - 0.1mg/kg)
        1. If seizure persists try one additional dose (risk of resp. depression incr if >2 doses)
        2. Effective duration of action is up to 4-6 hours
      2. Midazolam (0.1-0.3mg/kg)
      3. Diazepam
        1. Compared to lorazepam, less effective and more respiratory depression
    2. Fosphenytoin (15-20 mg/kg)
      1. Treat if seizure persists despite benzo tx
      2. Onset of action may take as long as 30 minutes
      3. Can cause hypotension and dysrhythmias
    3. Barbituates
      1. Consider only if benzos and phenytoin have failed
      2. May lead to respiratory depression, especially when preceded by a benzo
    4. Valproic acid
      1. Has been shown to be effective when benzos, phenytoin, and barbituates have failed
      2. Can be used as 2nd or 3rd-line treatment
    5. Propofol
  2. Treat underlying infection

Disposition

  • Discharge
    • Simple febrile seizure if pt at baseline, f/u w/in 1-2d
    • Complex febrile seizure if pt well-appearing, labs normal, f/u in 24hr
  • Admit:
    • Ill-appearing
    • Lethargy beyond postictal period


See Also

Seizure (Peds)

Fever (Peds)

Source

Tintinalli

[Category:Peds]]

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