Difference between revisions of "Febrile seizure"
(risk of epilepsy) |
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=== Simple versus Complex === | === 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 == | ==Differential Diagnosis == | ||
| − | + | *[[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 == | == Work-Up == | ||
| − | + | *Glucose in all pts | |
| − | + | *Simple febrile seizure | |
| − | + | **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 == | == 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<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 | |
== Disposition == | == Disposition == | ||
| Line 73: | Line 73: | ||
== See Also == | == See Also == | ||
| − | |||
*[[Seizure]] | *[[Seizure]] | ||
*[[Fever (Peds)]] | *[[Fever (Peds)]] | ||
| Line 80: | Line 79: | ||
<references/> | <references/> | ||
| − | [[Category:Peds]][[Category:Neuro]] | + | [[Category:Peds]] |
| + | [[Category:Neuro]] | ||
Revision as of 14:53, 1 May 2015
Contents
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
- 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[1]
Work-Up
- Glucose in all pts
- Simple febrile seizure
- Neither labs nor neuroimaging are absolutely necessary
- Normal 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
- Treat if initial seizure persists >5 min or for subsequent seizures
- Benzodiazepines
- 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
- Simple febrile seizure if pt at baseline
- Admit:
- Ill-appearing
- Lethargy beyond postictal period
See Also
Source
- ↑ Baxter P. et al. Pyridoxine‐dependent and pyridoxine‐responsive seizures. Developmental Medicine & Child Neurology 2001, 43: 416–42
- ↑ 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