a brief description of febrile seizures with 4 clinical cases

1. Febrile Seizures
By Hasan Ismail

2. Case presentation
ER : one of your patients is being evaluated for new-onset seizures.
The 2-year-old boy was in his normal state of good health until this
morning, when he complained of a headache and then fell to the floor.
While waiting for the ED physician to come to the phone. According to
the ED physician, the boy’s mother saw jerking of both arms and legs.
When the ambulance arrived 5 minutes later, the child had stopped
jerking but was not arousable

3. ; his heart rate was 108 bpm, respiratory rate 16 breaths/min, blood
pressure 90/60 mm Hg, and temperature 104°F (40°C). His blood sugar
level was 135 mg/dL. By the time the child arrived to the ED, he was
awake and he recognized his parents. His physical examination in the
ED is normal, as are his complete blood count and urinalysis.

4. Types
• SFC:
- infection. CNS ?
- Unrecognized epilepsy
- T.C.
• Complex AFS
- Focal
- Timing
- recurrence

5. Prognosis
• SFC : excellent, no intellectual defects
(70-80%)
• Atypical : cause ?
(20-30%)

6. What to do ?!

7. • Relax
• Recovery Position
• Hospital if > 5 mins

8. • 4-8 % of children
• Usually between 6 months and 6 years
• Average of 18 months

9. Stop Ongoing Seizure By:
- Diazepam : 0,2 mg/Kg IV, or
0,5 mg/Kg Rec.
- Midazolam : IV, 0,2 mg/Kg max : 5mg.
Buccal : 0,4 - 0,5 mg/Kg
Intranasal : 0,2 mg|Kg/dose
- Lorazepam: 0.05 - 0.1 MG/ KG/ dose

11. MAJOR RF for Recurrence
1- Onset of FS < 1 Year of age
2- Duration of fever < 24 hr
3- Fever 38-39

12. Indication for LP
• < 6 Mo
• Seizure occurring after 3 days of fever.
• Prolonged postictal phase.
• Complex (FS).
• No cause of fever.
• Anorexia.

14. Back to Case presentation
ER : one of your patients is being evaluated for new-onset seizures.
The 2-year-old boy was in his normal state of good health until this
morning, when he complained of a headache and then fell to the floor.
While waiting for the ED physician to come to the phone. According to
the ED physician, the boy’s mother saw jerking of both arms and legs.
When the ambulance arrived 5 minutes later, the child had stopped
jerking but was not arousable

15. ; his heart rate was 108 bpm, respiratory rate 16 breaths/min, blood
pressure 90/60 mm Hg, and temperature 104°F (40°C). His blood sugar
level was 135 mg/dL. By the time the child arrived to the ED, he was
awake and he recognized his parents. His physical examination in the
ED is normal, as are his complete blood count and urinalysis.

16. ➤ Questions ?
➤ Diagnosis?
➤ Best management for this condition?
➤ Course and prognosis ?

17. 1) Paramedics bring to the ED a 7-month-old infant with seizure activity.
The father reports the infant was in a normal state of health until
approximately 3 days ago when she developed a febrile illness, diagnosed
by her physician as a viral upper respiratory tract infection.
Approximately 30 minutes ago she began having left arm jerking, which
progressed to whole-body jerking. The episode spontaneously ceased on
the way to the hospital. Vital signs include heart rate 90 bpm, respiratory
rate 25 breaths/min, and temperature 100.4°F (38°C). Your examination
reveals a sleeping infant in no respiratory distress. The child’s
anterior fontanelle is full. The oropharynx is clear, and crusted mucous
is found in the nares. The tympanic membranes are dark and without
normal landmarks. The lungs are clear, and the heart and abdominal
examinations are normal. She has a bruise over the occiput and several
parallel bruises along the spine. Which of the following is the best next
step in management?

18. A. Computerized tomography (CT) of the head
B. Electroencephalogram
C. Lumbar puncture
D. Observation
E. Phenobarbital

19. 2) A 2-year-old boy who had a simple
brief febrile seizure comes to your office
1 day after his ED visit. He is currently
afebrile, is happily pulling the
sphygmomanometer off the wall, and is
taking antibiotics for an ear infection
diagnosed the previous day. His mother
wants to know what to expect in the
future regarding his neurologic status.
You correctly tell her which of the
following?

20. A. He has no risk of further seizures because he
was age 2 years at the time of his first febrile
seizure.
B. He will need to take anticonvulsant medications
for 6 to 12 months to prevent further seizure
activity.
C. You want to schedule an EEG and a magnetic
resonance scan of his head.
D. Although he does have a risk of future febrile
convulsions, seizures of his type are generally
benign and he is likely to outgrow them.
E. This is an isolated disorder, and his children will
not have seizures

21. 3) A 10-month-old boy presents to the ED with a 1-day
history of fever to 104°F (40°C), increased irritability,
decreased breast-feeding, and refusal of solid foods.
The parents brought him in after two 30-second
episodes of generalized jerking that occurred over a
20-minute span. Your examination reveals an awake
but lethargic infant. The anterior fontanelle is flat, the
tympanic membranes and oropharynx are moist
and not erythematous, the lungs are clear, and the
heart and abdominal examinations are normal. He has
no focal neurologic findings. Which of the following is
the best next step in management?

22. A. Intravenous ceftriaxone
B. Admission overnight for observation
C. Computerized tomography of the
head
D. Discharge from ED to follow up with
his primary care provider in 24 hours
E. Lumbar puncture

23. The father of a 4-year-old girl calls your office to
report her second febrile seizure. He states that
this seizure was identical to the first one that
happened 4 months ago: she developed an
elevated temperature and within a short time
had a generalized convulsion lasting 90 seconds.
She was sleepy for approximately 2 minutes
afterward. Upon awaking, she was given
ibuprofen. She is now running around the house,
chasing her younger brother and the family’s
chihuahua. The parents wonder if she needs to
take anticonvulsants now that she has had
another seizure. You should tell the father which
of the following?

24. A. Febrile seizures frequently are recurrent but
usually have no significant long-term effect.
B. You will prescribe an anticonvulsant because
it will reduce the risk of future epilepsy.
C. You will order an EEG and CT scan of her head
to be done on an outpatient basis.
D. He needs to take his daughter to the hospital
for inpatient admission.
E. He should stop the ibuprofen and observe the
fever curve.

25. ➤ Febrile seizures usually are benign and self-limited.
They do not require an
extensive diagnostic evaluation unless they are
prolonged or focal.
➤ A diagnosis of febrile seizure must be made only
after considering the possibility
of central nervous system infection as the seizure
cause.
➤ Febrile seizures rarely lead to epilepsy; risk
factors for nonfebrile seizures
include preexisting developmental abnormalities
and complex febrile
seizures.