Difference between revisions of "Febrile seizure"

(Simple Febrile Seizure)
 
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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
 
  
=== Simple versus Complex  ===
+
==Clinical Features==
*Simple
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*[[Seizure]] + [[fever]]
**Generalized tonic-clonic seizure
 
**&lt;15 min in duration
 
**Age 6mo - 6yr
 
**Occurs only once in 24hr period
 
**No focal features
 
*Complex
 
**Any exception to above
 
  
==Differential Diagnosis ==
+
===Simple Febrile Seizure===
*[[Meningitis ]]
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*Age 6mo-5yr, with majority occurring between 12mo-18mo
**More likely if [[status epilepticus]]
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*Single seizure in 24hr
*[[Seizure]] due to identifiable cause (e.g. intracranial mass, trauma, ingestion)
+
*Duration <15min
*Epidural/subdural infection or hematoma
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*Generalized with no focal features
*Toxic Ingestion
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*Returns to neurologic baseline and has normal neuro exam after brief post-ictal period
*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  ==
+
===Complex Febrile Seizure===
*Glucose in all pts
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*Any exception to above
*Simple febrile seizure  
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*May indicate more serious disease process
**Neither labs nor neuroimaging are absolutely necessary
+
 
**Normal [[Fever (Peds)|pediatric fever workup]]
+
==Differential Diagnosis==
*Complex febrile seizure  
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{{Pediatric seizure DDX}}
**Consider CBC, blood cx, UA, Ucx, CSF studies
+
 
 +
{{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:  
 
*Consider CT if:  
**Persistently abnormal neuro exam (esp w/ focality)  
+
**Persistently abnormal neuro exam (especially with focality)  
**Signs/symptoms of increased ICP  
+
**Signs/symptoms of [[increased ICP]]
**pt has VP shunt
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**Patient has [[VP shunt]]
 +
*Consider [[ECG]] if:
 +
**Family history of [[long QT]], [[Brugada]], sudden death
 
*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
 +
*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]]
  
== Treatment  ==
+
==Disposition==
*Treat if initial seizure persists &gt;5 min or for subsequent seizures
+
===Discharge===
**[[Benzodiazepines]]
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*Simple febrile seizure if patient at baseline
***[[Lorazepam]] 0.1mg/kg IV
+
**Follow-up in 1-2d
***[[Diazepam]] 0.2 mg/kg IV or 0.5 mg/kg PR (choice if difficult or no access)
+
**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>  
***[[Midazolam]] 0.1 mg/kg IV or IM or IN
+
*Complex febrile seizure if patient well-appearing, work-up normal
****If persists try one additional dose (risk of resp. depression incr if &gt;2 doses)
+
**Follow-up in 24hr
**[[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  ==
+
===Admit===
*Discharge
+
*Ill-appearing  
**Simple febrile seizure if pt at baseline
+
*Lethargy beyond postictal period
***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 ==
+
==See Also==
 
*[[Seizure]]
 
*[[Seizure]]
 
*[[Fever (Peds)]]
 
*[[Fever (Peds)]]
  
== Source  ==
+
==References==
 
<references/>
 
<references/>
  
[[Category:Peds]]
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[[Category:Pediatrics]]
[[Category:Neuro]]
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[[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