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
Febrile seizures in
• 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
• 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.
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
< 6 months or>60 months
< 15 minutes
> 15 minutes
Generalized tonic clonic
Non in 24 hours
Recurring in 24 hours
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%.
Risk factors of subsequent epilepsy :
Complex febrile seizure.
Family history of epilepsy.
The recurrence of episodes of feb.seizures in
a child does not increase the risk of
The risk of epilepsy following a simple febrile
seizure is 1-2.4% and following a complex
febrile seizure is 4.1-6%.
• 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 ?
How to approach a case of febrile seizures
Stable patient post sz
Counseling and family education
• 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
• Determine whether there is evidence of possible
central nervous system infection
(meningitis or encephalitis)*
• 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.
Recommendations for evaluation of simple febrile
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
• A complete blood count is useful in the evaluation of fever and possible
bacteremia particularly in children < 2 years but is not routinely
• Neuroimaging is not recommended for first simple febrile seizure.
Recommendations for evaluation of complex febrile
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
• 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
• 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
Brief directed Hx and Px
– if meningitis/encephalitis considered
ASSESS SEVERITY OF ILLNESS
Assess type of seizure
Identify and treat seriuos bactreial
Hospitalize in ICU
Persistent altered mental status or local signs
• Persistent altered mental status or focal signs
Discharge and follow up:
Contact in 24-48 h
Monitor for recurrence and for epilepsy
Recurrent febrile seizures
Consider prophylaxis with fever
Home rectal benzodiazepine