Rosen & Barkin's 5-Minute Emergency Medicine Consult (640 page)

TREATMENT

• Protect the airway
  
• Oxygen
  
• Support breathing as needed
  
• Cautions:
  
  • Keep child from incurring injury while actively convulsing
    
  • Respiratory insufficiency and apnea occur secondary to overaggressive treatment with benzodiazepines
    
  • Simple febrile seizures are self-limited and generally require no anticonvulsant therapy or ventilatory support
    

• Support the airway and breathing
  
• Benzodiazepines rarely needed:
  
  • Prolonged seizures or compromised patients
    
  • Lorazepam, diazepam, or midazolam
    
  • Rectal diazepam or nasal midazolam may be easily administered with good efficacy
    

• Rarely is pharmacologic intervention required; usually self-limited
  
• Seizures refractory to benzodiazepines:
  
  • Phenytoin or fosphenytoin
    
  • Phenobarbital
    
  • Workup to exclude other etiologies
    
• Administer antipyretics acutely and routinely for at least the next 24 hr:
  
  • Acetaminophen and/or ibuprofen (may use both)
    
• Appropriate antibiotic treatment for specific bacterial disease if identified
  
• Reassure and education of parents is essential
  

• Acetaminophen: 10–15 mg/kg/dose PO, PR; do not exceed 5 doses/24 h
  
• Diazepam: 0.2 mg/kg IV (max. 10 mg); 0.2–0.5 mg/kg PR (max. 20 mg)
  
• Fosphenytoin: 20 mg/kg IV over 20 min
  
• Ibuprofen: 10 mg/kg PO
  
• Lorazepam: 0.1 mg/kg IV (max. 5 mg)
  
• Midazolam: 0.05–0.1 mg/kg IV; 0.2 mg/kg buccal/IN/IM (max. 7.5 mg)
  
• Phenobarbital: 15–20 mg/kg IV over 20 min or IM; monitor for respiratory depression
  
• Phenytoin: 15–20 mg/kg IV over 30–45 min
  

FOLLOW-UP

• Recurrent or prolonged seizures
  
• Fever with source not appropriately treated as outpatient
  

• Simple febrile seizures:
  
  • Normal neurologic exam
    
  • Source of fever is appropriately treated as outpatient
    
• Reassurance to parents
  

Schedule follow-up with primary care physician

• Although aggressive treatment of fever with antipyretics is often recommended, there is no evidence that this reduces seizure recurrence
  
• Oral diazepam during febrile illness may reduce risk of recurrence; prophylactic anticonvulsants with other anticonvulsants rarely indicated—such treatment is controversial and to be considered only after extensive discussion
  

• Barata I. Pediatric seizures.
  Crit Decisions Emerg Med
  . 2005;19(6):1–21.
  
• Blumstein MD, Friedman MJ. Childhood seizures.
  Emerg Med Clin North Am
  . 2007;25:1061–1086.
  
• Hirabayashi Y, Okumura A, Kondo T, et al. Efficacy of a diazepam suppository at preventing febrile seizure recurrence during a single febrile illness.
  Brain Dev
  . 2009;31:414–418.
  
• Offringa M, Newton R. Prophylactic drug management for febrile seizures in children.
  Cochrane Database Syst Rev.
  2012;4:CD003031.
  
• Steering Committee on Quality Improvement and Management; Subcommittee on Febrile Seizures American Academy of Pediatrics. Febrile seizures: Clinical practice guideline for the long-term management of the child with simple febrile seizures.
  Pediatrics
  . 2008;121(6):1281–1286.
  
• Strengell T, Uhari M, Tarkka R, et al. Antipyretic agents for preventing recurrences of febrile seizures: Randomized controlled trial.
  Arch Pediatr Adolesc Med
  . 2009;163(9):799–804.
  
• Subcommittee on Febrile Seizures; American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure.
  Pediatrics
  . 2011;127(2):389–394.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Anticholinergic Poisoning
  
• Seizures, Pediatric
  
• Fever, Pediatric
  

CODES

• 780.31 Febrile convulsions (simple), unspecified
  
• 780.32 Complex febrile convulsions
  

BASICS

Sudden, abnormal discharges of neurons resulting in a change in behavior or function

• Febrile seizures
  
• Infection
  
• Idiopathic
  
• Trauma
  
• Toxicologic:
  
  • Ingestion
    
  • Drug action
    
  • Drug withdrawal
    
• Metabolic:
  
  • Hypoglycemia
    
  • Hypocalcemia
    
  • Hypo/hypernatremia
    
  • Inborn errors of metabolism
    
• Perinatal hypoxia
  
• Intracranial hemorrhage
  
• CNS structural anomaly or malformation
  
• Degenerative disease
  
• Psychogenic
  

DIAGNOSIS

• Subtle abnormal repetitive motor activity:
  
  • Facial movements
    
  • Eye deviations
    
  • Eyelid fluttering
    
  • Lip smacking/sucking
    
• Respiratory alterations
  
• Apnea
  
• Seizure activity:
  
  • Focal or generalized tonic seizures
    
  • Focal or multifocal clonic seizures
    
  • Myoclonic movements
    
• Generalized problems (metabolic, infection, etc.) may present with focal seizures
  

• Generalized seizures:
  
  • Tonic--clonic
    
  • Tonic
    
  • Clonic
    
  • Myoclonic
    
  • Atonic (“drop”)
    
  • Absence
    
• Partial or focal seizures:
  
  • Simple:
    
    • Consciousness maintained
      
  • Simple partial seizures:
    
    • Motor, sensory, and/or cognitive symptoms
      
    • Motor activity focal: 1 part or side
      
    • Paresthesias, metallic tastes, and visual or auditory hallucinations
      
  • Complex:
    
    • Consciousness impaired
      
    • Complex partial seizure
      
  • Simple partial seizure progresses with impaired consciousness:
    
    • Aura precedes altered consciousness; auditory, olfactory, or visual hallucination
      
    • May generalize
      
• Status epilepticus:
  
  • Generalized is most common
    
  • Sustained partial seizures
    
  • Absence seizures
    
  • Persistent confusion; postictal period
    

• Determine whether seizures are febrile or afebrile
  
• Determine type of seizure:
  
  • Partial vs. generalized
    
  • Presence of eye findings, aura, movements, cyanosis
    
  • Duration
    
  • State of consciousness, postictal state
    
  • Predisposing conditions/history/family history (syndromes with a genetic component)