Podcast
Questions and Answers
Which age group has the highest incidence of febrile seizures?
Which age group has the highest incidence of febrile seizures?
What is one major intervention to consider if a seizure lasts longer than 3 minutes?
What is one major intervention to consider if a seizure lasts longer than 3 minutes?
Which of the following is NOT a common cause of seizures in children?
Which of the following is NOT a common cause of seizures in children?
In managing a child having a seizure, what is the priority assessment to perform first?
In managing a child having a seizure, what is the priority assessment to perform first?
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What is the classification of a seizure that starts in one hemisphere but can spread to the entire brain?
What is the classification of a seizure that starts in one hemisphere but can spread to the entire brain?
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Which of the following statements about the nature of pediatric seizures is true?
Which of the following statements about the nature of pediatric seizures is true?
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Which seizure type is characterized by a sudden loss of muscle tone or strength?
Which seizure type is characterized by a sudden loss of muscle tone or strength?
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Which aspect is important to gather during the pre-seizure focused history?
Which aspect is important to gather during the pre-seizure focused history?
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What symptom is least likely associated with a generalized seizure?
What symptom is least likely associated with a generalized seizure?
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Which post-seizure observation is essential to determine the patient's condition?
Which post-seizure observation is essential to determine the patient's condition?
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Which condition is a potential risk factor for developing seizures due to hypercoagulable states?
Which condition is a potential risk factor for developing seizures due to hypercoagulable states?
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What physical exam finding would most likely indicate increased intracranial pressure (ICP)?
What physical exam finding would most likely indicate increased intracranial pressure (ICP)?
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Which of the following is not a relevant social history factor that might impact seizure risk?
Which of the following is not a relevant social history factor that might impact seizure risk?
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Which of the following criteria is NOT associated with febrile seizures?
Which of the following criteria is NOT associated with febrile seizures?
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What characteristic differentiates simple febrile seizures from complex febrile seizures?
What characteristic differentiates simple febrile seizures from complex febrile seizures?
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What is the primary management step upon encountering a patient with a febrile seizure in the emergency department?
What is the primary management step upon encountering a patient with a febrile seizure in the emergency department?
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Which of the following is a predisposing factor for febrile seizures?
Which of the following is a predisposing factor for febrile seizures?
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What specific evaluation is NOT recommended for a first simple febrile seizure?
What specific evaluation is NOT recommended for a first simple febrile seizure?
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Which factor could increase the risk of febrile seizures following vaccinations?
Which factor could increase the risk of febrile seizures following vaccinations?
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How often do simple febrile seizures recur within 24 hours?
How often do simple febrile seizures recur within 24 hours?
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What is a typical age range for the occurrence of febrile seizures?
What is a typical age range for the occurrence of febrile seizures?
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What is the likelihood of a child experiencing recurrent febrile seizures?
What is the likelihood of a child experiencing recurrent febrile seizures?
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What factor increases the risk of developing future epilepsy after a febrile seizure?
What factor increases the risk of developing future epilepsy after a febrile seizure?
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Which of the following is recommended for the comfort of a child during a febrile seizure?
Which of the following is recommended for the comfort of a child during a febrile seizure?
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If a child has a complex febrile seizure, what is a strong indication for admission?
If a child has a complex febrile seizure, what is a strong indication for admission?
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What is the recommended approach for caring for a child after a febrile seizure?
What is the recommended approach for caring for a child after a febrile seizure?
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What vaccination factors might indicate the need for a lumbar puncture in a child presenting with a simple febrile seizure?
What vaccination factors might indicate the need for a lumbar puncture in a child presenting with a simple febrile seizure?
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Which examination findings in a child with a seizure would increase the suspicion of Acute Bacterial Meningitis (ABM)?
Which examination findings in a child with a seizure would increase the suspicion of Acute Bacterial Meningitis (ABM)?
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What are some risk factors for developing ABM in children with fever and seizures?
What are some risk factors for developing ABM in children with fever and seizures?
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In the context of a 7-month-old child with seizures and a recent history of bronchitis treated with antibiotics, what is the immediate concern regarding the child's condition?
In the context of a 7-month-old child with seizures and a recent history of bronchitis treated with antibiotics, what is the immediate concern regarding the child's condition?
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What is a critical indication for performing a lumbar puncture in children presenting with seizures?
What is a critical indication for performing a lumbar puncture in children presenting with seizures?
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Which scenario reflects the new AAP guidelines regarding lumbar puncture in children presenting with simple febrile seizures?
Which scenario reflects the new AAP guidelines regarding lumbar puncture in children presenting with simple febrile seizures?
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What clinical sign would most likely prompt consideration of meningitis in a child undergoing seizure assessment?
What clinical sign would most likely prompt consideration of meningitis in a child undergoing seizure assessment?
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What is a major differentiating factor for diagnosing status epilepticus in a child with a prolonged seizure?
What is a major differentiating factor for diagnosing status epilepticus in a child with a prolonged seizure?
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What is a common characteristic of Juvenile Myoclonic Epilepsy (JME)?
What is a common characteristic of Juvenile Myoclonic Epilepsy (JME)?
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Which treatment option is specifically indicated for Infantile Spasms?
Which treatment option is specifically indicated for Infantile Spasms?
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In the Evaluation of Epilepsy Syndromes, which neuroimaging method is preferred?
In the Evaluation of Epilepsy Syndromes, which neuroimaging method is preferred?
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What unique feature distinguishes Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS)?
What unique feature distinguishes Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS)?
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What is an essential aspect of EEG evaluation after a first nonfebrile, unprovoked seizure?
What is an essential aspect of EEG evaluation after a first nonfebrile, unprovoked seizure?
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Which of the following is a defining characteristic of Lennox-Gastaut Syndrome?
Which of the following is a defining characteristic of Lennox-Gastaut Syndrome?
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Which statement accurately reflects the prognosis of treatment following a first seizure?
Which statement accurately reflects the prognosis of treatment following a first seizure?
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What is an urgent requirement specific to evaluating Infantile Spasms?
What is an urgent requirement specific to evaluating Infantile Spasms?
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Which characteristic is NOT associated with Absence Epilepsy?
Which characteristic is NOT associated with Absence Epilepsy?
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For seizures that do not fit a known epilepsy syndrome, which laboratory evaluation is crucial?
For seizures that do not fit a known epilepsy syndrome, which laboratory evaluation is crucial?
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Study Notes
Febrile Seizures
- Most common in children aged 6 months to 6 years.
Seizures in Children
- Common pediatric condition resulting from abnormal electrical discharges in the brain.
- Characterized by changes in consciousness, behavior, motor skills, or sensation.
Causes of Seizures
- Fever accounts for 50% of cases.
- Other causes include congenital malformations, metabolic abnormalities, infections, trauma, vascular events, tumors, drugs/poisonings, and idiopathic epilepsy (35%).
Types of Seizures
-
Partial Seizures:
- Simple
- Complex Partial
- Partial with Secondary Generalization
-
Generalized Seizures:
- Tonic-Clonic
- Tonic
- Clonic
- Absence
- Atonic
- Myoclonic
Emergency Protocol for Seizures
- Stay calm; do not run; track the duration of the seizure.
- Assess airway, breathing, and circulation (ABCs).
- Position the patient on their side to prevent aspiration.
- Provide oxygen, monitor O2 saturation, establish IV access, and check bedside glucose.
- If seizure lasts longer than 3 minutes, administer Lorazepam (0.05-0.1 mg/kg IV or IM).
Focused History Collection
-
Pre-seizure:
- Assess the child's well-being prior to the event.
- Inquire about prior seizures, history of fever or infections, recent antibiotic use, and access to adult medications.
-
Seizure:
- Observe for eye deviation, blank stare, drooling, cyanosis, incontinence, and tongue biting. Note duration and responsiveness.
-
Post-seizure:
- Evaluate mental status and any postictal state. Gather information on EMS observations.
Past Medical History (PMH)
- Consider history of neurosurgical procedures, prematurity, developmental delays, CNS infections, head trauma, and hypercoagulable states.
- Review medication history and family history of seizures or neurologic diseases.
- Investigate social history regarding toxic exposures and access to prescription medications.
Physical Exam
- Check vital signs including rectal temperature.
- Conduct a thorough examination of general appearance and mental status.
- Focus on:
- Focal neurologic deficits.
- Signs of increased intracranial pressure (bulging fontanelle, papilledema).
- Skin lesions (Ashleaf spots, shagreen patches, café au lait spots).
- Nuchal rigidity and poor perfusion.
- Altered motor tone and prolonged post-ictal lethargy.
- Presence of generalized petechiae.
Febrile Seizures
- Occur in children under 6 years associated with fever > 100.4°F, commonly exceeding 102°F.
- No signs of CNS infection or meningeal signs present during the seizure.
- No acute metabolic abnormalities or history of prior afebrile seizures.
- Typical onset between 6 months and 6 years, peaking at 12-18 months.
- Majority of febrile seizures happen on the first day of illness, often the child's first indication of sickness.
Predisposing Factors
- Mechanism linking fever to convulsions is unclear, likely due to multiple contributing factors.
- Can occur during both viral and bacterial infections, with increased rates seen in cases of HHV-6 and influenza.
- Risk also heightened following vaccinations for DTP and MMR (up to 14 days post-vaccination).
- Familial history may play a role in susceptibility to febrile seizures.
Simple vs. Complex Febrile Seizures
-
Simple Febrile Seizures:
- Last less than 15 minutes, generalized in nature without focal features.
- Do not recur within 24 hours.
-
Complex Febrile Seizures:
- Last more than 15 minutes and may show focal features or postictal paresis (Todd’s paralysis).
- Recur within 24 hours.
Evaluation & Management in the Emergency Department
- Key steps include stabilizing the patient and conducting a focused history and physical examination.
- Important to categorize the seizure as simple or complex.
- Assess the likelihood of intracranial infection and acute bacterial meningitis.
- Determine the necessity for diagnostic studies and establish the appropriate disposition.
Imaging and Laboratory Requirements
- For first simple febrile seizures, no imaging studies are needed.
- Laboratory evaluation offers no benefit in the assessment of simple febrile seizures.
- EEG is not recommended, along with neuroimaging (CT, MRI).
Vaccination and Antibiotics
- Inquire about the child's vaccination status and recent antibiotic use to assess risk factors for infections.
New AAP Guidelines for Lumbar Puncture (LP)
- Routine LP is not recommended for well-appearing, fully immunized children after a simple febrile seizure.
- LP should be performed in children exhibiting clear meningeal signs.
- LP is an option for children aged 6-12 months who are deficient in Hib and S. pneumoniae vaccinations or have received antibiotic treatment.
Case 3: 7-Month-Old Female with Seizure
- Presented with a 10-minute seizure, fever for 3 days, and current treatment with amoxicillin for bronchitis.
- Somnolent with mottled extremities, raising suspicion for Acute Bacterial Meningitis (ABM).
- Risk factors for ABM include: illness duration > 3 days, recent physician visit, antibiotic treatment for non-CNS infection, immunocompromised status, unvaccinated children, multiple seizures, and prolonged postictal state.
- Alarming symptoms include focal neurological deficits, persistent altered motor tone, nuchal rigidity, poor perfusion, and generalized petechiae.
Case 4: 4-Year-Old Male in Status Epilepticus
- Actively seizing for 30 minutes and not responsive to IV lorazepam, with a fever of 104°F and headache for 4 days.
- Status Epilepticus (SE) with fever significantly increases the risk for meningitis; incidence of ABM is ~12% in these cases.
- Clear guidelines indicate LP is warranted for SE presentations with fever.
Disposition of Febrile Seizures
- Children returning to baseline and having a reassuring clinical exam can typically be discharged.
- It's crucial to educate caregivers about the condition and management of febrile seizures.
- Prognosis indicates 33% of affected children may have recurrent febrile seizures, while 2% may develop epilepsy.
- Recurrence risk factors include: onset at a young age (<1 year), family history of febrile seizures, baseline developmental delays, and experiencing complex febrile seizures.
Antipyretics and Recurrence of Febrile Seizures
- Use of antipyretics for comfort is recommended but does not reduce the recurrence of febrile seizures.
Preventive Therapy
- Continuous or intermittent anticonvulsant therapy is not recommended due to the risks outweighing benefits.
- For immediate needs, rectal diazepam can be used on an as-needed basis.
- Reassure caregivers that febrile seizures are common, generally harmless, and do not increase epilepsy risks.
Discharge Instructions for Caregivers
- Educate parents on safety: keep the child in a safe position, place them on their side, ensure no objects are in the mouth, and perform chin lift/jaw thrust.
- Advise when to call EMS: if the child shows no signs of slowing down after 3 minutes.
Admission Criteria
- Admission may be necessary for prolonged postictal phases, complex febrile seizures, children under 6 months, or if there are social concerns.
Febrile Seizure Summary
- Majority of febrile seizures are simple and do not require lab evaluations or neuroimaging.
- Prophylactic anticonvulsants should not be routinely administered; parental education remains vital.
Epilepsy Syndromes
- Absence Epilepsy: Characterized by brief episodes of absence, which may include eyelid flutter.
- Juvenile Myoclonic Epilepsy (JME): Myoclonic jerks predominantly in the morning, onset during adolescence, can be triggered by stress, may include tonic-clonic and absence seizures.
- Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS): Symptoms include somatosensory changes, speech arrest, facial twitching, and drooling, with possible tonic-clonic seizures mainly at night or during sleep; often resolves by adulthood without the need for therapy.
- Infantile Spasms: Sudden flexion or extension movements in infants, requires urgent intervention; worse outcomes are noted if treatment is delayed past 12 months.
- Lennox-Gastaut Syndrome: Onset between 3-5 years, presents with mixed seizure types, commonly associated with severe developmental delay.
Evaluation of Epilepsy Syndromes
- EEG: Outpatient procedure; not urgent except for infantile spasms which need immediate assessment.
- Neuroimaging: MRI is the preferred method for evaluation.
- Infantile Spasms: Requires immediate EEG, MRI, and metabolic evaluation with neurological consultation and potential hospital admission.
Treatment Options for Epilepsy Syndromes
- Absence Epilepsy: Treated with ethosuximide, valproic acid, lamotrigine, or levetiracetam.
- JME: Managed with valproic acid, topiramate, or levetiracetam.
- BECTS: Generally does not require treatment; if needed, partial seizure AEDs are effective, especially carbamazepine.
- Infantile Spasms: Treated with ACTH, steroids, zonisamide, topiramate, or vitamin B-6.
- Lennox-Gastaut Syndrome: Often necessitates a combination of medications.
Evaluation of Seizures without Identified Epilepsy Syndrome
- Laboratory Evaluation: Tailored to clinical circumstances; may include assessments for electrolytes, glucose, calcium, magnesium, phosphate, ammonia, lactic acid, urine drug screening, lumbar puncture (if needed), and use of imaging techniques.
- CT vs. MRI: MRI is superior in identifying epileptogenic foci but is complex to perform in emergency settings.
- EKG and EEG: EKG screens for arrhythmias; EEG determines seizure type, epilepsy syndrome presence, and recurrence risk. All patients should have an EEG after their first non-febrile seizure.
Treatment and Disposition
- First Unprovoked Seizure: Majority of children do not experience frequent recurrences; no improved long-term seizure remission prognosis when treating after the first seizure vs. second seizure.
- Admission Criteria: Consider age (especially under 6 months), seizure etiology, control, and social considerations.
Summary
- Seizures are common in children, with febrile seizures being the most frequent initial presentations.
- Focus on evaluating the underlying fever rather than the seizure itself in cases of febrile seizures.
- Routine EEG and neuroimaging are often necessary for non-febrile seizures, except in urgent cases such as infantile spasms.
- No advantage in starting anticonvulsant therapy after the first seizure compared to waiting for a second seizure.
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Description
This quiz focuses on the evaluation and management of seizures in children, with a particular emphasis on febrile seizures prevalent among kids aged 6 months to 6 years. Explore the transient causes and characteristics of pediatric seizures, while understanding the various factors that may lead to such episodes in young patients.
