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Febril seizures

  1. 1. Febrile Seizure Dr Mallikarjun D Study Physician Dept Of Community Medicine KMC Manipal
  2. 2. Outline  Definitions  Aetiology  Classification  Clinical presentation  Treatment
  3. 3.  Abnormal neuronal activity  A sudden biochemical imbalance at the cell membrane  Repeated abnormal electrical discharges  Seen clinically as changes in motor control, sensory perception and/or autonomic function A Seizure Is:
  4. 4. Definition  Provoked seizures  Seizures induced by somatic disorders originating outside the brain  E.g. fever, infection, syncope, head trauma, hypoxia, toxins, cardiac arrhythmias
  5. 5. Definition Epilepsy • Present when 2 or more unprovoked seizures occur at an interval greater than 24 hours apart
  6. 6. Definition  Status epilepticus (SE)  Continuous convulsion lasting longer than 30 minutes OR occurrence of serial convulsions between which there is no return of consciousness  Idiopathic SE  Seizure develops in the absence of an underlying CNS lesion/insult  Symptomatic SE  Seizure occurs as a result of an underlying neurological disorder or a metabolic abnormality
  7. 7. Causes of seizures  Epileptic  Idiopathic (70-80%)  Cerebral tumor  Neurodegenerative disorders  Neurocutaneous syndromes  Secondary to  Cerebral damage: e.g. congenital infections, HIE, intraventricular hemorrhage  Cerebral dysgenesis/malformation: e.g. hydrocephalus
  8. 8. Causes of seizures  Non-epileptic  Febrile convulsions  Metabolic  Hypoglycemia  HypoCa, HypoMg, HyperNa, HypoNa  Head trauma  Meningitis  Encephalitis  Poisons/toxins
  9. 9.  Parents/caregivers may report seeing: Repetitive non-purposeful movements Staring Rolling of Eye balls – Upwards Lip-smacking Falling down without cause Stiffening of any or all extremities Rhythmic shaking of any or all extremities Clinical Presentation: Motor Changes
  10. 10.  Parents/caregivers may report the child is: Feeling nauseous Feeling odd or peculiar Losing control of bowel or bladder Feeling numbness, tingling Experiencing odd smells or sounds Clinical Presentation: Sensory and Autonomic
  11. 11.  Consciousness is the usual alertness or responsiveness the child demonstrates.  Parents/caregivers may report or you may observe the child to have: Baseline alertness Diminished level of consciousness Unresponsive and unconscious Clinical Presentation: Consciousness
  12. 12.  Apnea  Breath Holding  Dizziness  Myoclonus  Pseudoseizures  Psychogenic Seizures  Rigors  Syncope  Transient Ischemic Attacks Clinical Presentation: Events That Mimic Seizures
  13. 13. Seizure Classifications Generalized Partial Complex Simple Involves BOTH hemispheres of the brain Involves motor* or autonomic# symptoms with altered level of consciousness Can involve motor,* autonomic# or somatosensory+ symptoms Always involves loss of consciousness May start in one muscle group and spread May start in one muscle group and spread Types:  Tonic or clonic movements or combination (grand mal)  Absence (petit mal)  Myoclonic  Atonic (e.g., drop attacks)  Infantile spasms Types of symptoms: 1) Motor* - head/eye deviation, jerking, stiffening 2) Autonomic# - pupillary dilatation, drooling, pallor, change in heart rate or respiratory rate 3) Somatosensory+ - smells, alteration of perception (déjà vu)
  14. 14. Febrile seizures are the most common seizure disorder in childhood, affecting 2 - 5% of children between the ages of 6 months and 5 years Febrile Seizure5
  15. 15.  Caused by the increase in the core body temperature greater than 100.4o F or 38o C  Threshold of temperature which may trigger seizures is unique to each individual  Can occur within the first 24 hours of an illness Can be the first sign of illness in 25 - 50% of patients Febrile Seizure6
  16. 16.  Are benign  Occurrence: between 6 months to 5 years of age  May be either simple or complex type seizure  Seizure accompanied by fever (before, during or after) WITHOUT ANY  Central nervous system infection  Metabolic disturbance  History of previous seizure disorder Febrile Seizure: Characteristics
  17. 17. Simple Febrile  6 months – 5 years of age  Febrile before, during or after seizure  Includes all of the following  Seizure lasting less than 15 minutes  Generalized seizure  Occurs once in a 24-hour period Complex Febrile  6 months – 5 years of age  Febrile before, during or after seizure  One or more of the following  Prolonged (lasting more than 15 minutes)  Focal seizure  Occurs more than once in 24 hours Febrile Seizure: Two Types5
  18. 18.  Reassess temperature  Consider giving antipyretic if not previously administered  As source of fever is identified, treat appropriately Simple Febrile Seizure: ED Ongoing Management
  19. 19. Here are some frequently asked questions parents/caregivers may have prior to discharge: Is my child brain damaged? There is no evidence of impact on learning abilities after seizure from SFS. Will this happen again? If child is under 12 months of age at time of first seizure, recurrence rate is 50% If child is greater than 12 months of age at time of first seizure, recurrence rate is 30% Most recurrences occur within 6-12 months of the initial febrile seizure Simple Febrile Seizure: Family Education5,7
  20. 20.  Will my child get epilepsy? For simple febrile seizures, there is no increased risk of epilepsy  Why not treat for possible seizures or fever? Anticonvulsants can reduce recurrence. However potential side effects of medications outweigh the minor risk of recurrence Prophylactic use of antipyretics does not have impact on recurrence Simple Febrile Seizure: Family Education5,7 (cont.) For complex febrile seizures, there is a slight increase in the risk of epilepsy. For complex febrile seizures, there is a slight increase in the risk of epilepsy.
  21. 21.  Instruct parent/caregivers to prevent injury during a seizure: Position child while seizing in a side-lying position Protect head from injury Loosen tight clothing about the neck Prevent injury from falls Reassure child during event Do not place anything in the child’s mouth Simple Febrile Seizure: Family Education8 (cont.)
  22. 22. Prior to discharge home…  Educate regarding use of: Thermometer Antipyretics for fever management When to contact 9-1-1 or ambulance  Identify a Primary Care Provider for follow-up appointment and stress importance of follow-up  Provide developmentally appropriate explanation of event for child and family members Simple Febrile Seizure: Disposition

Editor's Notes

  • The next few slides review the basics of seizure activity. When a seizure occurs, there are changes at the cellular level leading to abnormal activity of the nerve endings. The biochemical imbalances result in an abnormal repetition of electrical discharges at the nerve junctions. Clinically, the child shows changes in motor control, alterations in sensory perception, and or altered autonomic function.
     
  • Some commonly observed motor behaviors include: repetitive, non-purposeful movements of any body part; staring; lip-smacking; falling without a cause; stiffening of any extremity; or rhythmic shaking of any extremity. If these motor behaviors can be interrupted by verbal or physical stimulation, they are not considered seizure activity.
  • Common sensory symptoms described by a parent or caregiver may include: feeling nauseous, odd or peculiar; losing bowel or bladder control; or feeling numb or tingling anywhere on the body. Also, experiencing odd smells or sounds may be noted.
  • The last aspect of clinical presentation is the child’s level of consciousness while experiencing the motor, sensory, and autonomic symptoms. This may vary and is compared to the child’s usual baseline level. The level of consciousness may be somewhat diminished as compared to baseline or the child may be unresponsive and unconscious.
  • A careful history from a reliable witness is essential in evaluating a child who presents with a reported seizure.
    Since witnessing a seizure can create a highly charged emotional environment, it is important to identify characteristics of seizures and consider conditions which may mimic seizures in order to make an accurate diagnosis. Breath holding, apnea, syncope, and dizziness should be considered as alternative diagnoses. Tics, myoclonus, rigors, and shuddering can be misinterpreted as changes in motor control. Psychogenic and pseudoseizures are clinically similar to epileptic seizures, but do not result from an abnormal electrical discharge from the brain.
  • Seizures are classified with respect to where the abnormal neuronal activity occurs. With generalized seizures, both hemispheres of the brain are involved and there is loss of consciousness. Movements are tonic or clonic or a combination. Absence seizures are also generalized. Partial seizures may be simple or complex, and involve only one hemisphere of the brain. In complex partial seizures, there is altered level of consciousness, while in simple partial seizures there is NO loss of consciousness; however, there may be transient cognitive impairments. Movements begin with a single muscle group and then spread in both complex and simple partial seizures. The different types of symptoms that may occur include motor symptoms such as - head/eye deviation, jerking, stiffening; autonomic symptoms, such as - pupillary dilatation, drooling, pallor, change in heart rate or respiratory rate, as well as somatosensory symptoms, such as smells and/or alteration of perception (for example déjà vu).
  • Febrile seizures are the most common seizure disorder in childhood, affecting less than five percent of children between the ages of six months and five years.
  • A febrile seizure is a seizure accompanied by a fever whose cause is unknown. Each child has an unique temperature threshold that might trigger a seizure. Febrile seizures can occur within the first 24 hours of an illness, and be the first sign of illness in 25 to 50 percent of patients.
  • Febrile seizures are a benign condition. They occur in children between the ages of six months to five years. For a febrile seizure diagnosis to be established, the child must have no other history of seizures, metabolic diseases, or signs of central nervous system infections, such as meningitis. Febrile seizures can be either simple or complex.
  • A simple febrile seizure is defined as a generalized seizure lasting less than 15 minutes that occurs once in 24 hours. In contrast, a complex febrile seizure lasts greater than 15 minutes or has focal elements or occurs more than once in 24 hours. The American Academy of Pediatrics has developed clinical practice guidelines for evaluation and management of a simple febrile seizure. However, there are no consensus guidelines for complex febrile seizure management at this time.
  • Emergency Department management focuses on reassessment of the child’s temperature, administration of antipyretics as ordered by the physician, and appropriate treatment for the source of the fever, when identified.
     
  • Febrile seizures are a benign condition. There is no evidence of learning disabilities from febrile seizures. The largest risk is recurrence. The risk of recurrence is related to the age of the child at the time of the first seizure. If a child is under 12 months of age at the time of first seizure, the recurrence rate is 50%. If the child is greater than 12 months at the time of the first seizure, the recurrence rate is 30%.
  • Research indicates there is no increased risk of epilepsy if a child had a simple febrile seizure. While anticonvulsants can reduce the minor risk of recurrence, potentially negative side effects outweigh the benefit. Similarly, prophylactic use of antipyretics is not effective in preventing recurrent febrile seizures.
  • Family education should include instruction to protect the child during the seizure. Seizure precautions revolve around protecting the child from injury, such as positioning the child in a side-lying fashion, protecting the head, loosening tight clothing about the neck, and reassuring the child. Remind parents and caregivers they should not place objects in the child’s mouth to avoid tongue biting or swallowing.
  • Although antipyretic treatment has not been shown to be effective in the prevention of recurrence, parents and caregivers do still need instruction on fever management based on the source of the fever. Reviewing appropriate use of 9-1-1 or ambulance transport is also important. Many recommend calling after 5 minutes of seizure activity or if the child doesn’t regain consciousness between seizures. Typically, children who have had a simple febrile seizure are discharged home with primary care follow-up. Older children will need explanation in an age appropriate way to understand the experience in a non-threatening way.
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