Febrile seizure (pediatrics): Clinical sciences

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Introduction0:00–0:25

Febrile seizures occur in children 6 months to 5 years of age, with a temperature of at least 38 degrees Celsius, and without concurrent central nervous system infection, metabolic disturbance, or history of prior afebrile seizures.
Based on the child’s manifestations, febrile seizures can be classified as simple or complex.Now, if a pediatric patient presents with a chief concern suggesting febrile seizure, you should first perform an ABCDE assessment to determine whether they are unstable or stable.

Unstable Patient0:25–2:06

If the patient is unstable, first stabilize the airway, breathing, and circulation, obtain IV access, and consider starting IV fluids.
Next, put your patient on continuous vital sign monitoring, including heart rate, blood pressure, and oxygen saturation.
Finally, if needed, don’t forget to provide supplemental oxygen to maintain saturation, and consider administering an anti-seizure medication.Now here’s a clinical pearl to keep in mind!
If your patient experiences a seizure in front of you, and the seizure activity persists for 5 minutes or more, place them on their side, on a flat surface, and administer a short-acting benzodiazepine such as IV lorazepam or IM midazolam as first choices, or rectal diazepam as second choice.
If the seizure doesn’t resolve after two doses of a benzodiazepine or after 20 minutes of seizure activity, administer a different anti-seizure medication, such as IV phenobarbital if your patient is an infant, or IV fosphenytoin if they are an older child.
A febrile seizure lasting longer than 30 minutes is considered febrile status epilepticus, which is a neurologic emergency requiring the prompt administration of additional anti-seizure medication and further diagnostic evaluation.Now, let's go back and take a look at stable patients.

Stable Patient2:06–3:03

In this case, your first step is to obtain a focused history and physical exam. History typically reveals a high or rapidly rising fever before the onset of a seizure.
Ask the caregivers to describe the seizure activity, which could be generalized or limited to one extremity. Caregivers might also report a recent infection associated with high fever, such as roseola, or recent administration of immunizations, such as diphtheria-tetanus-pertussis or measles-mumps-rubella.
In addition, there might be a family history of febrile seizures. Finally, the physical examination will often reveal a temperature of at least 38 degrees Celsius, possibly with tachycardia.
Moreover, if the seizure recently resolved, your patient may display postictal drowsiness or confusion.With these findings, you should suspect a febrile seizure, so your next step is to assess your patient’s age and look for signs of central nervous system infection.

Suspect febrile seizure3:03–3:14

Alternative diagnosis3:14–4:04

If your patient is under 6 months of age, or if the physical exam reveals signs suggesting central nervous system infection, such as irritability or bulging fontanelles, then you should consider alternative diagnoses, like meningitis.
Now, here’s a clinical pearl to keep in mind! Children with febrile seizures have an increased likelihood of a central nervous system infection like bacterial meningitis if they are between 6 and 12 months old, and are not fully immunized against Haemophilus influenzae type B and Streptococcus pneumoniae; or if they have had recent antibiotic use, since antibiotics can mask the signs and symptoms of meningitis.
These children should undergo further evaluation for central nervous system infection after a first febrile seizure.On the other hand, if the child is between 6 months and 5 years of age, and the exam reveals no signs of a CNS infection, then you can diagnose a febrile seizure.

No signs of CNS infection4:04–4:26

Once you diagnose it, your next step is to assess the seizure characteristics and the neurologic exam findings.First, let’s discuss simple febrile seizures.

Simple febrile seizures4:26–5:48

For these children, the history will reveal a seizure that lasted less than 15 minutes and did not recur within 24 hours.
In addition, the seizure will be described as generalized, with tonic-clonic, tonic, or atonic motor activity. Additionally, on the physical exam, there will be an absence of focal neurologic signs such as weakness or paralysis.
With these findings, you can diagnose a simple febrile seizure. Now, let’s move on to the management of a simple febrile seizure.
First, offer antipyretics for fever control, and treat any underlying condition, such as otitis media. Next, educate caregivers and reassure them that simple febrile seizures commonly recur, but they typically resolve by 5 years of age without long-term neurological sequelae.
Finally, keep in mind that in this age group, you don’t need an additional seizure evaluation, like neuroimaging and EEG, because simple febrile seizures are not associated with intracranial structural abnormalities or epileptic disorders.Alright, now let’s switch gears and discuss complex febrile seizures.

Complex febrile seizures5:48–7:34

In this case, the history typically reveals a seizure that lasts 15 minutes or longer, or that recurs within 24 hours.In addition, caregivers may describe a focal seizure, for example, motor activity limited to one extremity.
Additionally, the physical exam might reveal focal neurologic signs, such as weakness or paralysis. Your patient might also demonstrate Todd paresis, also called postictal paralysis, which is a temporary unilateral weakness or paralysis occurring after a seizure.
With these findings you can diagnose a complex febrile seizure.Now that you’ve made the diagnosis, it’s time to move on to management.
First, offer antipyretics for fever control, and treat any underlying condition, such as otitis media. Next, educate the child’s caregivers that children with complex febrile seizures have an increased risk of developing epilepsy when compared to children with simple febrile seizures.
Accordingly, don’t forget to obtain further seizure evaluation! You should order an EEG and an MRI of the brain to look for possible intracranial structural abnormalities, especially if your patient presents with focal neurological signs.
Moreover, all children with febrile status epilepticus have complex febrile seizures, and should undergo additional evaluation, which typically includes neuroimaging, EEG, as well as lumbar puncture.Alright, as a quick recap… Febrile seizures occur in children aged 6 months to 5 years of age with a temperature of at least 38 degrees Celsius, without concurrent central nervous system infection, metabolic disturbance, or history of prior afebrile seizures.

Review7:34–8:42

Once you identify a febrile seizure, details from the history and physical exam can distinguish simple from complex febrile seizures.
Simple febrile seizures last less than 15 minutes, do not recur within 24 hours, and are generalized in nature. Management includes antipyretics, treatment of any underlying infection, and caregiver reassurance and education.
Simple febrile seizures require no further evaluation. Conversely, complex febrile seizures can last longer than 15 minutes, recur within 24 hours, and are usually focal in nature.
Management includes antipyretics, treatment of any underlying infection, and caregiver education. In addition, children with complex febrile seizures should be evaluated with EEG and MRI.
Febrile seizure (pediatrics): Video and Causes | Osmosis