Difference between revisions of "Febrile seizure"

(Treatment)
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== Treatment  ==
 
== Treatment  ==
 +
===Ongoing Seizure===
 
*Treat if initial seizure persists >5 min or for subsequent seizures  
 
*Treat if initial seizure persists >5 min or for subsequent seizures  
 
**[[Benzodiazepines]]
 
**[[Benzodiazepines]]
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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
 +
 +
===Seizure Stopped===
 +
*Simple
 +
**Treat fever source per normal if indicated
 +
*Complex
 +
**Treat source if indicated from workup
  
 
== Disposition  ==
 
== Disposition  ==

Revision as of 15:03, 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

Clinical Presentation

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]

Diagnosis

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

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

Ongoing Seizure

  • 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

Seizure Stopped

  • Simple
    • Treat fever source per normal if indicated
  • Complex
    • Treat source if indicated from workup

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