A General Approach to Febrile Seizures
Case:
A 4 year old boy, otherwise healthy, is rushed into the emergency room by his mom because she thinks he had a seizure. His mom states he was sitting on the ground playing a game on his iPad when he suddenly started having jerking movements of his entire body that eventually self resolved after around 2 minutes. He has never had a seizure before. He is up to date on vaccines and had an unremarkable birth history.
On exam, the child is not actively seizing at this time, he just seems slightly drowsy and confused. It is noted that he is febrile to 38.2 C, otherwise vitals are stable. The rest of the exam is nonfocal.
What should you be thinking about? What are your next steps?
Simple Febrile Seizure
Definition: Mostly occurs in ages 6 months to 6 years; generalized tonic clonic seizure that resolves in less than 15 minutes in the setting of a fever (>38 C).
Intervention: None. Most of the time, no further work up is needed besides observation.
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Intervention can focus on determining the cause of the fever (i.e. obtaining further history from parents, focal findings on exam, etc.).
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An LP can be performed if there are clinical signs of meningitis.
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An LP should also be performed if the child is between 6months and 1 year and has not received his/her Haemophilus influenzae type B or Streptococcus pneumoniae vaccines.
Going forward: Children who have a simple febrile seizure are at the same risk of having epilepsy as the general population. They can be discharged home safely.
Complex Febrile Seizure
Definition: Any seizure that lasts >15 minutes, is focal, occurs more than once in 24 hours, or occurs in a child less than 6 months or older than 6 years.
Intervention: Treat the seizure if still active upon arrival to the emergency room. Otherwise, intervention is the same as simple febrile seizures.
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If the child appears ill, can consider performed an LP and other necessary infectious work up.
Going forward: Formal neurology evaluation and blood work (electrolytes) should be obtained if a complex seizure is associated with concerning features
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Concerning features: focality, Todd’s paralysis, no return to baseline mental status, and developmental delay.
References:
Hart, J, et al. Emergency Department Evaluation and Inpatient Clinical Pathway for
Evaluation/Treatment of Children with Febrile Seizures without Neurologic Disease.
Children’s Hospital of Philadelphia, June 2016.
Tintinalli, Judith E, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide.
Ninth edition. New York: McGraw-Hill Education, 2020.