Febrile seizure
Background
- 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
DDx
- 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
- Benzodiapazines
- Lorazepam 0.1mg/kg IV
- Diazepam 0.2 mg/kg IV or 0.5 mg/kg PR
- 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 tx
- 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]
- Benzodiapazines
- 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