Evaluation and Management of Pediatric Febrile Seizures in the Emergency Department

https://doi.org/10.1016/j.emc.2010.08.008Get rights and content

Section snippets

Case definitions

For research and clinical purposes, pediatric febrile seizures have been divided into two categories: simple (typical) and complex (atypical).4 The case definition of simple febrile seizure is rigid and exclusive. The definition of complex febrile seizure is less structured, essentially encompassing a heterogeneous group of pediatric seizures with fever that cannot be classified as simple febrile seizure.4 To be termed a simple febrile seizure, a case must meet all of the criteria presented in

Clinical assessment

Patients who have experienced a febrile seizure will present more emergently than febrile age-matched “controls” without seizure.2, 3 Parental anxiety is typically high, and prehospital interventions such as intravenous line placement and supplemental oxygen can contribute to the child’s distress. Perhaps because of the ominous implications of seizures accompanying fever in adults, clinicians historically have had a tendency to perform aggressive diagnostic workups on these children.6

If the

Laboratory testing in patients with simple febrile seizures

Studies have shown that the measurement of serum electrolytes or glucose has no role in the evaluation of simple febrile seizures.10, 11, 12 Similarly, no evidence suggests that emergent CT of the brain is useful in these cases.11, 13 The literature supports the finding that these children are at no greater risk for serious bacterial infection than age-matched controls who have not seized. In other words, the occurrence of a simple febrile seizure seems to contribute no independent risk for

Laboratory tests in patients with complex febrile seizures

Complex febrile seizures include a heterogeneous array of conditions, and no standardized approach can be recommended. In each instance, the clinician must determine how far outside the definition of a simple febrile seizure a particular case falls. Investigations should be directed at the elements that raise the greatest concern. For example, the febrile child in status epilepticus may be at risk for electrolyte abnormalities, toxic ingestions, traumatic brain injury, or meningitis. The

Emergent imaging in patients with complex febrile seizures

The American Academy of Pediatrics practice guideline for the acute management of simple febrile seizures does not recommend emergency neuroimaging because intracranial abnormalities are rare in these patients.4 No practice guidelines recommend emergent neuroimaging in patients presenting with a complex febrile seizure.

Teng and colleagues28 performed a retrospective review of prospectively collected data examining the risk of emergent intracranial pathologic conditions in patients presenting

Discharge instructions for children with a simple febrile seizure

The prognosis for children who experienced a simple febrile seizure is excellent. However, most caregivers have just witnessed an extraordinarily stressful episode. Successful discharge instructions consist of information provided to parents in a clear, reassuring and understanding manner. In some cases an extended period of observation in the ED may be indicated simply to convince parents that a period of grave danger has passed.

Because by definition all cases have presented with a fever,

Summary

Febrile seizure is a very common childhood condition. Although the recurrence rate is fairly high (roughly one-third), the overall prognosis is excellent and the risk of developing epilepsy is low (approximately 1%). The occurrence of a simple febrile seizure is not an independent risk factor for serious bacterial infection, and aggressive diagnostic evaluations are rarely indicated. Round-the-clock prophylactic administration of antipyretics have not been shown to affect the incidence of

First page preview

First page preview
Click to open first page preview

References (45)

  • C. Johnston et al.

    Pediatric prehospital care in a southern regional emergency medical service system

    South Med J

    (1988)
  • Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures

    Pediatrics

    (1996)
  • P.K. Duffner et al.

    Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. American Academy of Pediatrics. Steering Committee on Quality Improvement and Management. Subcommittee of Febrile Seizures

    Pediatrics

    (2008)
  • L.C. Hampers et al.

    Setting based practice variation in the management of simple febrile seizure

    Acad Emerg Med

    (2000)
  • F.U. Knudsen

    Febrile seizures: treatment and prognosis

    Epilepsia

    (2000)
  • L.A. Rolak et al.

    Clinical features of Todd’s post-epileptic paralysis

    J Neurol Neurosurg Psychiatry

    (1992)
  • F. Leutmezer et al.

    Postictal signs of lateralizing and localizing significance

    Epileptic Disord

    (2002)
  • N. Rutter et al.

    Calcium, magnesium, and glucose levels in blood and CSF of children with febrile convulsions

    Arch Dis Child

    (1976)
  • M.A. Gerber et al.

    The child with a “simple” febrile seizure. Appropriate diagnostic evaluation

    Am J Dis Child

    (1981)
  • M. Jaffe et al.

    Fever and convulsions—indications for laboratory investigations

    Pediatrics

    (1981)
  • S. Teach et al.

    Incidence of bacteremia, urinary tract infections and unsuspected bacterial meningitis in children with febrile seizures

    Pediatr Emerg Care

    (1999)
  • S.M. Green et al.

    Can seizures be the sole manifestation of meningitis in febrile children?

    Pediatrics

    (1993)
  • Cited by (23)

    • Myelin water fraction changes in febrile seizures

      2018, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      Prior studies have shown that approximately one third of children with a first-time FS episode will subsequently experience a recurrent event [6–8]. Recurrence appears to be more likely in subjects with a family history of FS, those who present at earlier than 18 months of age, those who present with temperatures <40 °C at first convulsion, those with multiple seizures during the same febrile illness, children who attend day nursery, and those who have a seizure within 1 h of febrile illness onset [6–10]. Children with none of these risk factors have a 4% chance of having further FS, while children with all of these risk factors can have up to 80% chance of further episodes [9–11].

    • Should patients with complex febrile seizure be admitted for further management?

      2018, American Journal of Emergency Medicine
      Citation Excerpt :

      Complex febrile seizures (CFSs) are defined as those with focality, prolonged duration (> 15 min), and/or multiple seizures within 24 h [2]. Approximately 20–30% of children with a first febrile seizure will have subsequent febrile seizures [3-6]. There are currently no clinical practice guidelines regarding management of CFS in the US.

    • Inpatient admission for febrile seizure and subsequent outcomes do not differ in children with vaccine-associated versus non-vaccine associated febrile seizures

      2014, Vaccine
      Citation Excerpt :

      Beyond the first recurrence, 48% of our patients had additional FS, which is consistent with published data [13]. It may be that our lower rates of first recurrence reflect FS care management and education [28]. Caregivers are informed at the first FS visit that recurrence is common and that home management is generally a safe option for subsequent simple FS events.

    • Febrile seizures: Risks, evaluation and prognosis

      2012, American Family Physician
      Citation Excerpt :

      In a 20-year retrospective review of 526 cases of bacterial meningitis, 93 percent of patients presented with altered consciousness.18 Routine laboratory studies in patients with simple febrile seizures are discouraged because electrolyte abnormalities and serious bacterial illnesses are rare.16,19,20 In a retrospective review of 379 children with simple febrile seizures, only eight were found to have bacteremia.21

    View all citing articles on Scopus
    View full text