Difference between revisions of "Febrile seizure"

(risk of epilepsy)
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=== Simple versus Complex  ===
 
=== Simple versus Complex  ===
#Simple  
+
*Simple  
##Generalized tonic-clonic seizure  
+
**Generalized tonic-clonic seizure  
##<15 min in duration  
+
**<15 min in duration  
##Age 6mo - 6yr  
+
**Age 6mo - 6yr  
##Occurs only once in 24hr period  
+
**Occurs only once in 24hr period  
##No focal features
+
**No focal features
#Complex  
+
*Complex  
##Any exception to above
+
**Any exception to above
  
 
==Differential Diagnosis ==
 
==Differential Diagnosis ==
#[[Meningitis ]]
+
*[[Meningitis ]]
##More likely if [[status epilepticus]]
+
**More likely if [[status epilepticus]]
#[[Seizure]] due to identifiable cause (e.g. intracranial mass, trauma, ingestion)  
+
*[[Seizure]] due to identifiable cause (e.g. intracranial mass, trauma, ingestion)  
#Epidural/subdural infection or hematoma
+
*Epidural/subdural infection or hematoma
#Toxic Ingestion
+
*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>
+
*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  ==
 
== Work-Up  ==
#Glucose in all pts  
+
*Glucose in all pts  
#Simple febrile seizure  
+
*Simple febrile seizure  
##Neither labs nor neuroimaging are absolutely necessary
+
**Neither labs nor neuroimaging are absolutely necessary
##Normal [[Fever (Peds)|pediatric fever workup]]
+
**Normal [[Fever (Peds)|pediatric fever workup]]
#Complex febrile seizure  
+
*Complex febrile seizure  
##Consider CBC, blood cx, UA, Ucx, CSF studies
+
**Consider CBC, blood cx, UA, Ucx, CSF studies
#Consider CT if:  
+
*Consider CT if:  
##Persistently abnormal neuro exam (esp w/ focality)  
+
**Persistently abnormal neuro exam (esp w/ focality)  
##Signs/symptoms of increased ICP  
+
**Signs/symptoms of increased ICP  
##pt has VP shunt
+
**pt has 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
  
 
== Treatment  ==
 
== Treatment  ==
#Treat if initial seizure persists &gt;5 min or for subsequent seizures  
+
*Treat if initial seizure persists &gt;5 min or for subsequent seizures  
##[[Benzodiazepines]]
+
**[[Benzodiazepines]]
###[[Lorazepam]] 0.1mg/kg IV  
+
***[[Lorazepam]] 0.1mg/kg IV  
###[[Diazepam]] 0.2 mg/kg IV or 0.5 mg/kg PR (choice if difficult or no access)
+
***[[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
+
***[[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)
+
****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)
+
**[[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  
+
***Treat if seizure persists despite benzo treatment  
###Onset of action may take as long as 30 minutes  
+
***Onset of action may take as long as 30 minutes  
###Can cause [[hypotension]] and [[dysrhythmias]]
+
***Can cause [[hypotension]] and [[dysrhythmias]]
##[[Barbituates]]
+
**[[Barbituates]]
###[[Phenobarbital]] 15-20 mg/kg IV
+
***[[Phenobarbital]] 15-20 mg/kg IV
###Consider only if benzos and phenytoin have failed  
+
***Consider only if benzos and phenytoin have failed  
###May lead to respiratory depression, especially when preceded by a benzo
+
***May lead to respiratory depression, especially when preceded by a benzo
##[[Valproic acid]] 10-15 mg/kg IV (20 mg/min)
+
**[[Valproic acid]] 10-15 mg/kg IV (20 mg/min)
###Has been shown to be effective when benzos, phenytoin, and barbituates have failed  
+
***Has been shown to be effective when benzos, phenytoin, and barbituates have failed  
###Can be used as 2nd or 3rd-line treatment
+
***Can be used as 2nd or 3rd-line treatment
##[[Keppra]] 20 mg/kg IVP
+
**[[Keppra]] 20 mg/kg IVP
##[[Propofol]] 2-3 mg/kg IVP; maintenance 0.125-0.3 mg/kg/min IV
+
**[[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]] (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
+
**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>
 
Childhood.1983 (58) 415-418. http://adc.bmj.com/content/58/6/415.full.pdf</ref>
#Treat underlying infection
+
*Treat underlying infection
  
 
== Disposition  ==
 
== Disposition  ==
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== See Also  ==
 
== See Also  ==
 
 
*[[Seizure]]
 
*[[Seizure]]
 
*[[Fever (Peds)]]
 
*[[Fever (Peds)]]
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<references/>
 
<references/>
  
[[Category:Peds]][[Category:Neuro]]
+
[[Category:Peds]]
 +
[[Category:Neuro]]

Revision as of 14:53, 1 May 2015

Background

  • 2-3% chance of developing epilepsy (1% for general population)
  • 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

  • Simple
    • Generalized tonic-clonic seizure
    • <15 min in duration
    • Age 6mo - 6yr
    • Occurs only once in 24hr period
    • No focal features
  • Complex
    • Any exception to above

Differential Diagnosis

  • Meningitis
  • Seizure due to identifiable cause (e.g. intracranial mass, trauma, ingestion)
  • Epidural/subdural infection or hematoma
  • Toxic Ingestion
  • Pyridoxine Responsive Seizure[1]

Work-Up

  • Glucose in all pts
  • Simple febrile seizure
  • 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

  • Treat if initial seizure persists >5 min or for subsequent seizures
    • Benzodiazepines
      • 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 >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[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

Source

  1. Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
  2. 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