Questions and Answers
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?
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?
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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?
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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?
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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?
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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)?
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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?
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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?
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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?
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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?
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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?
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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?
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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?
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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)?
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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?
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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?
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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?
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What is a common characteristic of Juvenile Myoclonic Epilepsy (JME)?
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Which treatment option is specifically indicated for Infantile Spasms?
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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)?
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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?
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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?
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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?
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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.
