Difference between revisions of "Febrile seizure"

(Treatment)
(Simple Febrile Seizure)
 
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== Background ==
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==Background==
*50% of pts never have temp >39
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*Occur in 2-5% of American children before age 5<ref>https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/febrile-seizures-fact-sheet</ref>
*50% of pts &lt;12 mo will have another simple febrile seizure
+
*50% of patients never have temperature >39
*30% of pts &gt;12 mo will have another simple febrile seizure
+
*Febrile seizures do not increase the risk of serious bacterial illness
  
=== Simple versus Complex  ===
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===Prognosis===
#Simple
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*2-3% chance of developing epilepsy (1% for general population)
##Generalized tonic-clonic seizure  
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*50% of patients <12 mo will have another simple febrile seizure  
##&lt;15 min in duration
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*30% of patients >12 mo will have another simple febrile seizure
##Age 6mo - 6yr
 
##Occurs only once in 24hr period
 
##No focal features
 
#Complex
 
##Any exception to above
 
  
== DDx ==
+
==Clinical Features==
#Meningitis
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*[[Seizure]] + [[fever]]
##More likely if status epilepticus
 
#Seizure due to identifiable cause (e.g. intracranial mass, trauma, ingestion)
 
#Epidural/subdural infection or hematoma
 
  
== Work-Up  ==
+
===Simple Febrile Seizure===
#Glucose in all pts
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*Age 6mo-5yr, with majority occurring between 12mo-18mo
#Simple febrile seizure  
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*Single seizure in 24hr
##Neither labs nor neuroimaging are absolutely necessary
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*Duration <15min
##Normal [[Fever (Peds)|pediatric fever workup]]
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*Generalized with no focal features
#Complex febrile seizure
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*Returns to neurologic baseline and has normal neuro exam after brief post-ictal period
##Consider CBC, blood cx, UA, Ucx, CSF studies
 
#Consider CT if:
 
##Persistently abnormal neuro exam (esp w/ focality)
 
##Signs/symptoms of increased ICP
 
##pt has VP shunt
 
#Routine EEG not indicated
 
##Consider only if developmental delay or for focal symptoms
 
  
== Treatment  ==
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===Complex Febrile Seizure===
#Treat if initial seizure persists &gt;5 min or for subsequent seizures
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*Any exception to above
##Benzodiapazines
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*May indicate more serious disease process
###Lorazepam 0.1mg/kg IV
 
###Diazepam 0.2 mg/kg IV or 0.5 mg/kg PR
 
###Midazolam 0.1 mg/kg IV or IM or IN
 
####If persists try one additional dose (risk of resp. depression incr if &gt;2 doses)
 
##Fosphenytoin (15-20 mg/kg) or Phenytoin 10-20 mg/kg IV up to 1g @ 1mg/kg/min
 
###Treat if seizure persists despite benzo tx
 
###Onset of action may take as long as 30 minutes
 
###Can cause hypotension and dysrhythmias
 
##Barbituates
 
###Phenobarbital 15-20 mg/kg IV
 
###Consider only if benzos and phenytoin have failed
 
###May lead to respiratory depression, especially when preceded by a benzo
 
##Valproic acid 10-15 mg/kg IV (20 mg/min)
 
###Has been shown to be effective when benzos, phenytoin, and barbituates have failed
 
###Can be used as 2nd or 3rd-line treatment
 
##Keppra 20 mg/kg IVP
 
##Propofol 2-3 mg/kg IVP; maintenance 0.125-0.3 mg/kg/min IV
 
##Consider Pyridoxine (vitamin B6) 1g per g of INH ingested or 5g if unknown (in D5W IV over 30 min)
 
#Treat underlying infection
 
  
== Disposition  ==
+
==Differential Diagnosis==
*Discharge
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{{Pediatric seizure DDX}}
**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  ==
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{{Pediatric fever DDX}}
  
 +
==Evaluation==
 +
*The key is to distinguish between simple febrile seizure secondary to minor illness vs. seizure from serious central nervous system infection, which may also present with fever and seizure.
 +
*Glucose in all patients
 +
 +
====Simple febrile seizure====
 +
*Neither labs nor neuroimaging are absolutely necessary
 +
*Normal [[Fever (Peds)|pediatric fever workup]]
 +
 +
====Complex febrile seizure====
 +
*Consider CBC, [[blood culture]], UA, urine culture, [[CSF studies]]
 +
*Consider CT if:
 +
**Persistently abnormal neuro exam (especially with focality)
 +
**Signs/symptoms of [[increased ICP]]
 +
**Patient has [[VP shunt]]
 +
*Consider [[ECG]] if:
 +
**Family history of [[long QT]], [[Brugada]], sudden death
 +
*Routine EEG not indicated
 +
**Consider only if developmental delay or for focal symptoms
 +
*Causes amenable to specific treatment
 +
**[[Hypoglycemia]]
 +
**[[Hyponatremia]] (water intoxication, dilution of formula)
 +
**[[Hypocalcemia]]
 +
**[[Hypomagnesemia]]
 +
**[[INH ingestion]]
 +
 +
[[File:Febrile Seizure.png|thumb|Algorithm for the differentiation between simple and complex febrile seizures. Guidelines for evaluation of each.]]
 +
 +
==Management==
 +
===Ongoing Seizure===
 +
See [[Seizure (peds)]]
 +
 +
===Seizure Stopped===
 +
*Treat underlying infection if indicated
 +
**See [[pediatric fever of uncertain source]]
 +
 +
==Disposition==
 +
===Discharge===
 +
*Simple febrile seizure if patient at baseline
 +
**Follow-up in 1-2d
 +
**Around-the-clock [[acetaminophen]] may prevent seizure recurrence in the same febrile episode<ref>Murata et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. November 2018, VOLUME 142 / ISSUE 5</ref>
 +
*Complex febrile seizure if patient well-appearing, work-up normal
 +
**Follow-up in 24hr
 +
 +
===Admit===
 +
*Ill-appearing
 +
*Lethargy beyond postictal period
 +
 +
==See Also==
 
*[[Seizure]]
 
*[[Seizure]]
 
*[[Fever (Peds)]]
 
*[[Fever (Peds)]]
  
== Source  ==
+
==References==
*Tintinalli
+
<references/>
  
[[Category:Peds]]
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[[Category:Pediatrics]]
 +
[[Category:Neurology]]

Latest revision as of 17:00, 18 March 2020

Background

  • Occur in 2-5% of American children before age 5[1]
  • 50% of patients never have temperature >39
  • Febrile seizures do not increase the risk of serious bacterial illness

Prognosis

  • 2-3% chance of developing epilepsy (1% for general population)
  • 50% of patients <12 mo will have another simple febrile seizure
  • 30% of patients >12 mo will have another simple febrile seizure

Clinical Features

Simple Febrile Seizure

  • Age 6mo-5yr, with majority occurring between 12mo-18mo
  • Single seizure in 24hr
  • Duration <15min
  • Generalized with no focal features
  • Returns to neurologic baseline and has normal neuro exam after brief post-ictal period

Complex Febrile Seizure

  • Any exception to above
  • May indicate more serious disease process

Differential Diagnosis

Pediatric seizure

Pediatric fever

Evaluation

  • The key is to distinguish between simple febrile seizure secondary to minor illness vs. seizure from serious central nervous system infection, which may also present with fever and seizure.
  • Glucose in all patients

Simple febrile seizure

Complex febrile seizure

Algorithm for the differentiation between simple and complex febrile seizures. Guidelines for evaluation of each.

Management

Ongoing Seizure

See Seizure (peds)

Seizure Stopped

Disposition

Discharge

  • Simple febrile seizure if patient at baseline
    • Follow-up in 1-2d
    • Around-the-clock acetaminophen may prevent seizure recurrence in the same febrile episode[3]
  • Complex febrile seizure if patient well-appearing, work-up normal
    • Follow-up in 24hr

Admit

  • Ill-appearing
  • Lethargy beyond postictal period

See Also

References

  1. https://www.ninds.nih.gov/disorders/patient-caregiver-education/fact-sheets/febrile-seizures-fact-sheet
  2. Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
  3. Murata et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics. November 2018, VOLUME 142 / ISSUE 5