Febrile seizure: Difference between revisions

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== Background ==
==Background==
*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 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)
*2-3% chance of developing epilepsy (1% for general population)
*50% of pts&nbsp;never have temp >39
*50% of patients <12 mo will have another simple febrile seizure  
*50% of pts &lt;12 mo will have another simple febrile seizure  
*30% of patients >12 mo will have another simple febrile seizure
*30% of pts &gt;12 mo will have another simple febrile seizure
 
==Clinical Features==
*[[Seizure]] + [[fever]]
 
===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 DDX}}
 
{{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]]


=== Simple versus Complex ===
====Complex febrile seizure====
#Simple
*Consider CBC, [[blood culture]], UA, urine culture, [[CSF studies]]
##Generalized tonic-clonic seizure
*Consider CT if:
##&lt;15 min in duration
**Persistently abnormal neuro exam (especially with focality)
##Age 6mo - 6yr
**Signs/symptoms of [[increased ICP]]
##Occurs only once in 24hr period
**Patient has [[VP shunt]]
##No focal features
*Consider [[ECG]] if:
#Complex
**Family history of [[long QT]], [[Brugada]], sudden death
##Any exception to above
*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]]


==Differential Diagnosis ==
[[File:Febrile Seizure.png|thumb|Algorithm for the differentiation between simple and complex febrile seizures. Guidelines for evaluation of each.]]
#[[Meningitis ]]
##More likely if [[status epilepticus]]
#[[Seizure]] due to identifiable cause (e.g. intracranial mass, trauma, ingestion)
#Epidural/subdural infection or hematoma
#Toxic Ingestion
#Pyridoxine Responsive Seizure<ref>Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42</ref>


== Work-Up  ==
==Management==
#Glucose in all pts
===Ongoing Seizure===
#Simple febrile seizure
See [[Seizure (peds)]]
##Neither labs nor neuroimaging are absolutely necessary
##Normal [[Fever (Peds)|pediatric fever workup]]
#Complex febrile seizure
##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  ==
===Seizure Stopped===
#Treat if initial seizure persists &gt;5 min or for subsequent seizures
*Treat underlying infection if indicated
##[[Benzodiazepines]]
**See [[pediatric fever of uncertain source]]
###[[Lorazepam]] 0.1mg/kg IV
###[[Diazepam]] 0.2 mg/kg IV or 0.5 mg/kg PR (choice if difficult or no access)
###[[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 PE/kg IV) or [[Phenytoin]] (10-20 mg/kg IV up to 1g @ 1mg/kg/min)
###Treat if seizure persists despite benzo treatment
###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  (in D5W IV over 30 min)
##Consider Pyridoxine Responsive Seizure Disorder - 100mg/pyridoxine is generally effective<ref>Pyridoxine dependent seizures a wider clinical spectrum. Archives of Disease in
Childhood.1983 (58) 415-418. http://adc.bmj.com/content/58/6/415.full.pdf</ref>
#Treat underlying infection


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


== See Also  ==
===Admit===
*Ill-appearing
*Lethargy beyond postictal period


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


== Source  ==
==References==
<references/>
<references/>


[[Category:Peds]][[Category:Neuro]]
[[Category:Pediatrics]]
[[Category:Neurology]]

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
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