Febrile seizures in emergency department


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  • Focal seizures Tonic and/or clonic Partial seizure with/without generalization Head or eye deviation to one side Unilateral transient paralysis after seizure Loss of muscle tone.
  • altered mental status, severe headache, or focal neurologic signs before the seizure. Was there evidence of acute increase in intracranialpressure?
  • meningismus is absent in about one third of infants with meningitis. Does the child complain of significant headache or is there persistence of altered mental status subsequent to the seizure? Are there signs of increased intracranial pressure, such as abnormal eye movements (e.g., “setting sun” sign), excessive vomiting, unstable vital signs, or even papilledema?
  • Febrile seizures in emergency department

    1. 1. Febrile seizures in emergency department Dr.Tarek Sayed
    2. 2. Background • Febrile seizures are the most common type of seizures observed in the pediatric age group . • Definition :- a febrile seizure is defined as a seizure associated with febrile illness without a CNS infection or other cause (such as electrolyte imbalance) in a child not known to have epilepsy. • Another definition from the International League Against Epilepsy (ILAE) is "a seizure occurring in childhood after 1 month of age associated with a febrile illness not caused by an infection of the central nervous system (CNS), without previous neonatal seizures or a previous unprovoked seizure, and not meeting the criteria for other acute symptomatic seizures".
    3. 3. Incidence : • About 3 in 100 children have a febrile seizure sometime before their sixth birthday. They most commonly occur between the ages of 18 months and three years. They are rare in children aged under six months and over the age of six years.
    4. 4. Febrile seizures are characterized into two groups: simple febrile seizures and complex febrile seizures. Basically, if the child does not meet the criteria for a simple febrile seizure it is called a complex febrile seizure. Simple febrile seizures Complex febrile sezures age 6-60 months < 6 months or>60 months duration < 15 minutes > 15 minutes type Generalized tonic clonic Focal recurrence Non in 24 hours Recurring in 24 hours
    5. 5. Factors associated with increased risk of recurrence : • • • •  Younger age < 18 months. Family history of febrile seizures. Low peak temperature. Shorter duration of fever. The risk of having another febrile seizure after the first episode is 29-35%.
    6. 6. Risk factors of subsequent epilepsy : • • • • Neurodevelopmental abnormality. Complex febrile seizure. Family history of epilepsy. The recurrence of episodes of feb.seizures in a child does not increase the risk of subsequent epilepsy.  The risk of epilepsy following a simple febrile seizure is 1-2.4% and following a complex febrile seizure is 4.1-6%.
    7. 7. Case scenario: • 2 years old child • • • • parents “shaking episode” lasting “10 mins” EMS called - child no longer shaking. V/S - BP 105/60 HR 100 RR 18 Sat N T 39 HOW TO APPROACH ?
    8. 8. How to approach a case of febrile seizures Stable patient post sz • • • • • • • History Physical examination Laboratory studies Imaging EEG Treatment Counseling and family education
    9. 9. History • 1st focus the initial history on the nature of the seizure: preseiz. – during seiz. – after seiz • 2ry Focus on the history of fever, duration of fever, and potential exposures to illness. • A history of the cause of fever (eg, viral illnesses, gastroenteritis) should be elucidated. • Recent antibiotic use is particularly important because partially treated meningitis must be considered. • Determine whether there is evidence of possible central nervous system infection (meningitis or encephalitis)*
    10. 10. Physical examination • The underlying cause for the fever should be sought. • A careful physical examination often reveals otitis media, pharyngitis, or a viral exanthem. • Although bacterial meningitis is present in a small minority (2%–5%) of children with apparent febrile seizures, a high level of suspicion is important especially in the young infant.*careful neurological exam. Is a must.
    11. 11. Recommendations for evaluation of simple febrile seizures  from the American Academy of Pediatrics and the International League Against Epilepsy include: • Lumbar puncture is strongly recommended for < 12 months olds, should be considered in 12-18 month olds. Lumbar puncture is always recommended if there are meningeal signs in patients of any age. Previously antibiotic treatment could mask meningeal signs and lumbar puncture should be strongly considered in those cases. • EEG is not recommended to be performed for first simple febrile seizure. • Routine electrolytes, calcium, phosphorous, magnesium are not recommended for first simple febrile seizure unless indicated for other reason such as acute diarrhea that may predispose to electrolyte abnormalities. • A complete blood count is useful in the evaluation of fever and possible bacteremia particularly in children < 2 years but is not routinely recommended. • Neuroimaging is not recommended for first simple febrile seizure.
    12. 12. Recommendations for evaluation of complex febrile seizures  from the International League Against Epilepsy include: • Lumbar puncture: Evaluation for a source of possible infection including a lumbar puncture for any patient with suspected meningeal signs . • Routine chemistry tests are not recommended but should be considered based upon clinical conditions . • EEG is recommended. • Neuroimaging is highly recommended
    13. 13. Management: • The child with simple febrile seizures rarely needs acute intervention other than treatment of the underlying illness and fever. Parents need counseling and reassurance. • When necessary, manage febrile seizures with benzodiazepines. Manage status epilepticus as a medical emergency Consider rectal diazepam in the home setting because it is rapidly absorbed and is safe and effective. Persistent alteration of mental status may require emergency department observation and subsequent hospitalization. • A child who has a febrile seizure usually doesn't need to be hospitalized. If the seizure is prolonged or is accompanied by a serious infection, or if the source of the infection cannot be determined, a doctor may recommend that the child be hospitalized for observation
    14. 14. Treatment considerations • • • • ABC’s Brief directed Hx and Px Glucose Antibiotics/Antivirals – if meningitis/encephalitis considered
    15. 15. SE treatment • 1st line anticonvulsants – IV • lorazepam 0.1mg/kg • diazepam 0.2 mg/kg • midazolam 0.2 mg/kg – rectal diazepam • 2-5 yrs – 0.5 mg/kg • 6-11 yrs – 0.3 mg/kg • >12 yrs – 0.2 mg/kg – IM, intranasal, buccal midazolam
    16. 16. SE Treatment • 2nd line agents – phenytoin 20 mg/kg @ 1mg/kg/min (upto 50 mg/min) – fosphenytoin 15-20 PE/kg @ 3 mg/kg/min (upto 150 mg/min) • 3rd line agents – phenobarbital 20mg/kg @ 100mg/min – repeat prn 5-10mg/kg – maximum 40 mg/kg or 1 gram
    17. 17. Refractory SE treatment • consider midazolam – 0.2 mg/kg bolus – then 1-10 mcg/kg/min infusion • induce barbiturate coma – pentobarbital 5-15 mg/kg @ 25 mg/min – then 1-5 mg/kg/hour • others – – – – valproic acid paraldehyde, chloral hydrate propofol, inhalational anesthesia, paralysis lidocaine
    18. 18. Patient with febrile seizures Hitory Phsical examinatiopn Consider cultures LP,CBC,CRP,Urine analysis,U/E
    19. 19. • ASSESS SEVERITY OF ILLNESS severe Mild/moderate Assess type of seizure simple Identify and treat seriuos bactreial Inf.,bacteremia,meningitis,pnemonia UTI/pyelonephritis,bacterial enteritis complex assess Treat:Benzodizepine if needed,Education reasurance no yes Status epilepticus Shock Coma Resp. failure hypoxia Stabilize Hospitalize in ICU Consider hospitalization Persistent altered mental status or local signs Very severe
    20. 20. • Persistent altered mental status or focal signs No Discharge and follow up: Contact in 24-48 h Monitor for recurrence and for epilepsy no recurrence Recurrent febrile seizures Treat Consider prophylaxis with fever Home rectal benzodiazepine Non febrile seizure/epilepsy Consider AEDS
    21. 21. THANK YOU