Febrile seizure

Background

• 50% of pts never have temp >39
• 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. Age 6mo - 6yr
   4. Occurs only once in 24hr period
   5. 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, ingestion)
3. Epidural/subdural infection or hematoma

Work-Up

1. Glucose in all pts
2. Simple febrile seizure
   1. Neither labs nor neuroimaging are absolutely necessary
   2. Normal pediatric fever workup
3. Complex febrile seizure
   1. Consider CBC, blood cx, UA, Ucx, CSF studies
4. Consider CT if:
   1. Persistently abnormal neuro exam (esp w/ focality)
   2. Signs/symptoms of increased ICP
   3. pt has VP shunt
5. 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 0.1mg/kg IV
      2. Diazepam 0.2 mg/kg IV or 0.5 mg/kg PR
      3. Midazolam 0.1 mg/kg IV or IM or IN
         1. If persists try one additional dose (risk of resp. depression incr if >2 doses)
   2. Fosphenytoin (15-20 mg/kg) or Phenytoin 10-20 mg/kg IV up to 1g @ 1mg/kg/min
      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. Phenobarbital 15-20 mg/kg IV
      2. Consider only if benzos and phenytoin have failed
      3. May lead to respiratory depression, especially when preceded by a benzo
   4. Valproic acid 10-15 mg/kg IV (20 mg/min)
      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. Keppra 20 mg/kg IVP
   6. Propofol 2-3 mg/kg IVP; maintenance 0.125-0.3 mg/kg/min IV
2. Treat underlying infection

Disposition

• Discharge
  • Simple febrile seizure if pt at baseline
    • Follow-up in 1-2d
  • Complex febrile seizure if pt well-appearing, work-up normal
    • Follow-up in 24hr
• Admit:
  • Ill-appearing
  • Lethargy beyond postictal period

See Also

• Seizure
• Fever (Peds)

Source

• Tintinalli