extern conference january 3 rd 2008. case a thai 2 years 10 months old girl chief complaint...
TRANSCRIPT
Case
A Thai 2 years 10 months old girl
Chief ComplaintGeneralized tonic clonic
seizure 15 minutes prior to arrival
History of present illness 2 days ago, She had high grade
fever and loss of appetite. Her mother gave her paracetamol and tepid sponge. She vomited food when she ate.
A day before, She had high grade fever as well and passed watery stool once. Her mother took her to a hospital.
History of present illness Doctor at a Hospital nearby her
house gave her paracetamol, simethicone, motilium, amoxicillin, pseudoephridine and ORS.
After she came back home she still had high fever and got seizure.
During the seizure, her arms and legs was stretch out and no clonus, eyes was stared up. Duration of Seizure was 2 min. After the seizure she slept for one hour.
History of present illness Her mother brought her to Siriraj
Hospital. At ER, after the seizure she awoke
without focal neurological deficit. The doctor at ER administered aspirin
syrup and discharged her from ER. The same day, 15 min prior to arrival
she had recurrent seizure. The pattern of seizure was the same as the first time, however she also had clonic movement of her extremities.
She came back to Siriraj hospital and was admitted.
Past medical history She is a healthy girl. She had two episode of
seizures when she had high grade fever at the age of 1 year old. She did not hospitalization and no anticonvulsant agent was administered.
Family History
Her father had an episode of seizure with high grade fever when he was a child.
She had no family history of epilepsy.
Others history
Development: normal Vaccination: Complete according
to EPI Nutrition:
Rice for 2 meals with soy milk 6 boxes/day
Drugs & allergySulfa group hypersensitivity No drug used continuously
Physical Examination Vital Signs T 38 °c PR 136 /min
RR 36 /min BP 119/57 mmHg BW 18.7 Kg (> P99th) Ht 96 cm (P90th-97th)
Weight for height = 133.57 % General Appearance
Alert, active, no sunken eye balls, not pale, no jaundice, no skin lesion, no cyanosis, no clubbing of finger, capillary refill < 2sec
HEENT mild injected pharynx and tonsil, tonsils enlargement 3+, TM not injected
Physical Examination CVS regular pulse, normal S1 S2,
no murmur RS Normal breath sounds, no
adventitious sounds Abdomen Soft, mild distention,
not tender No hepatosplenomegalyActive bowel sounds
Physical Examination NS E4V5M6, good
consciousness, all CN were intact, fundoscopic examination can’t evaluate (uncooperative)
normal muscle tone, motor power grade 5 all extremities, no stiff neck
Investigation
Complete blood count:Hb 11.9 g/dl Hct 36.4 %
MCV 70.9 fLWbc 20,420 /mm3 N 86.9 % L 5.4
% M 5.3 % Eo 0.4 %Platelet 240,000 /mm3
Peripheral blood smear: normochromic microcytic RBCsplatelet : adequeteWBC : neutrophils predominate,
no band form, toxic granule 1+
Investigation
Urinalysis:pH 5 Sp.gr.1.015Albumin neg Sugar neg
Acetone neg Rbc 0-1 /HPF Wbc 0-1 /HPFbacteria 1+
Investigation
Na 134 mmol/L K 3.7 mmol/L Cl 101 mmol/L HCO3 19 mmol/L Magnesium 2.2
mg/dl Corrected Ca 4.8 mg/dl
Problem List
febrile seizure which lasted 15 mins and 4 hrs PTA High grade fever, watery diarrhea, vomiting for 1
day Family Hx of febrile seizure in the young : His
father Hx of febrile seizure at 1 year old Mild injected pharynx and tonsils Tonsilar enlargement 3+
Differential diagnosis
Febrile seizure CNS infection Intracranial hemorrhage Metabolic causes Shigellosis
Febrile seizure
Simple febrile
seizure
Complex febrile seizure
Lasts less than 15 minutes
Occurs once in a 24-hour period
Generalized
No previous neurologic problems
15Lasts minute s or l onger
O OOOOO O OOO OOOO - - once in a 2 4 hour
per i od
Focal
Patient has kno wn neurologic probl
ems, such as cerebr al pal sy
Intracranial hemorrhage
Subarachnoid hemorrhage Peri/intraventricular hemorrhage Subdural hemorrhage
Febrile seizure
OO OOOOOO OO . et al. : OOOOOOOO OO O O ildren. Pediatr Clin N Am 2006; 53 (25
7 277– ). Michelle D. Blumstein et al . : Childhood Sei
zures. Emerg Med Clin N Am 2 0 0 7 ; 25
(1 0 6 1 –1 0 8 6 ).
Febrile seizure
C onvulsion that occurs in associati on with a febrile illness in children
between 6 months and 5 years of age in the absence of an identifiab
le cause . Febrile seizures are the most com
mon type of seizure in young child ren, with a 2% to 5% incidence of c
hildren experiencing at least one s eizure before the age of 5 years.
Febrile seizure
Simple febrile
seizure
Complex febrile seizure
Lasts less than 15 minutes
Occurs once in a 24-hour period
Generalized
No previous neurologic problems
15Lasts minute s or l onger
O OOOOO O OOO OOOO - - once in a 2 4 hour
per i od
Focal
Patient has kno wn neurologic probl
ems, such as cerebr al pal sy
Febrile seizure
The peak age for febrile convulsi ons is between 18 and 24 month
s. The exact pathophysiology is un
known , but it seems that a fever lowers the seizure threshold.
F amily history of febrile seizures present in 25% to 40% of childre
n with febrile seizures.
When to Do a l umbar puncture?E 1very child < year OO OOO O OOO
a febrile convulsion.POOOOOOO OO O OOOOOOOO OOOOO OO
d symptoms. OOOO OO OOOOOO , O f LP is not perfo
rmed , the paediatrician is advised to review the case within a few
hours.
Investigation : LP
HKJ Paediatr (newseries)-2002714315; :
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Not necessary in most cases,but exceptions in a child withpapilledema cranial nerve palsies (eg. 6th ne
rve palsy) other persisting focal neurologi
cal signs (eg. hemiparesis) marked depression in mental statu
s
Investigation : Imaging
HKJ Paediatr (newseries)-2002714315; :
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R arely indicated in the manag ement of a simple febrile conv
ulsion Complex febrile seizure
Investigation : EEG
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E lectrolytes and sugar in a chi ld who is drowsy or
dehydration T oxicology screening if
suspicious
Investigation : Blood chemistry
HKJ Paediatr (newseries)-2002714315; :
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Acute management : general Same as other type of seizure Maintain a clear airway (ABC!!!) Give oxygen if available Apply suction for nasal or oral secretio
ns if facility available - Place the child in a semi prone position Protect the child from injury Loosen clothing or remove excess clot
hing Monitor vital sign
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Acute management : terminate seizure Benzodiazepines are the first drug of cho
ice for persistent seizure activity. Diazepam is the most common drug
used - 0205administer rectal diazepam . . mg/kg
/IV dose is 0.3 mg/kg/doseThe same dose can be repeated every 10 to
30 minutes to a total of 3 doses, if necessary Lorazepam IV form is not available in
Thailand
HK J Paediatr (new series 2002) ;7 -143:151
Observation for several hours after a febrile convulsion
Patients with a simple febrile seizure may be safely dischar
ged to home with parental reassurance and seizure education .
F ollow up care
Acute management
C omplex febrile seizure S uspicious of possibility of me
ningitis and encephalitis A ge < 18 months A nxious parents or inadequat
e home care
Hospital Admission: indication
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Management : fever Identify cause of fever S ponging with tepid water Antipyretics
Paracetamol 10-15 mg/kg/dose orally every 4-6 h
Paracetamol 10-15 mg/kg/dose IM form if oral route cannot be administered
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Recurrent Febrile ConvulsionsManagement Intermittent prophylaxis Continuous prophylaxis
HK J Paediatr (new series 2002) ;7 -143:151
Antipyretics and tepid sponge. Diazepam prophylaxis seems to be eff
ective in reducing the recurrence rate. S uggested doses for prophylaxis
0.5 mg/kg administered orally, or recta lly every 12 hr whenever the rectal tem
perature is > 38.5 ํC M aximum of 4 consecutive doses
Side effects of diazepam ataxia, lethargy and irritability
Management : intermittent prophylaxis
HK J Paediatr (new series 2002) ;7 -143:151
- Long term Anticonvulsant ProphylaxisP henobarbitone or sodium valproateCurrently N ot advise due to
• No definitive evidence that anticonvu lsants can prevent later epilepsy
•S ide effects of medicationsO nly use in highly selected case
• based on clinical circumstances and t he judgement of the benefit and its s ide effects
Management : continuous prophylaxis
HK J Paediatr (new series 2002) ;7 -143:151
Recurrence Risk of Febrile Convulsion Risk of recurrence is~ - 25 30% Major predictor for recurrence of febril
e convulsion•E arly age of onset
Other predictors;•Duration of fever before febrile seizure
•Temperature at onset of seizure•Family history of febrile seizure, Prolonged seizure
Prognosis and outcome
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Risk factor for epilepsy
C hildren with febrile seizure have only a 1% to 2% lifetime risk
R isk factors for epilepsy F amily history of epilepsy C omplex febrile seizure U nderlying neurologic disorder
If two or more of these risk factorspresent , the future risk of developing ep
ilepsy is 1 0 %. G eneral population have 05 1. % to %
lifetime risk of devel opi ngepi l epsy
Intellectual Deficit ? I ntellectual outcome is good Risk of Intellectual Deficit
P - re exi sti ngneurol ogi cal or d evelopmental abnormality
T hose who developed subsequ ent afebrile convulsions
Reassurance and education is thus very important.
Information to be provided toparents:
Parental education and reassurence
What should I do if my c hild has
a convulsion in the future?
• Stay calm. • Look at your watch or a c
lock and time the convulsion.
• Do not try to restrain yo ur child
and do not put anything intheirmouth.
• Stay with your child and lay them on their side.
• Loosen tight clothing fro m around
the neck and move object s away
that may cause injury. • Arrange to see your local
doctor/general practitione r after
the convulsion has stopped.
What is febrile convulsion?
Recurrence risk/Prognosis
What should I do whe n my child
develops fever in thefuture?
Siriraj hospital : Clinical practice guildline
Patient with fever and seizure (age 6 month – 5 years)1.History
taking
2.Physical examination
Assess cause of fever
•Tepid sponge
•Antipyretics
•Treat infection
Assess risk factor
• Age
• Neurological PE
• Type of seizure
•Age<12 month or 12-18 month with evidence of CNS infection
•Abnormal neurologicl exm
•Complex febrile convulsion
Consider LP CT scan or EEG
Normal investigation
Abnormal investigation
•Age > 18 months
•Normal neurologicl exm
Simple febrile convulsion
Treat accordingly
If first seizure >>Reassure and follow up
If recurrence >> Discuss about oral diazepam prophylaxis
Progression
First day, she had not repeated convulsions but still high grade fever and minimal watery stool.
By physical examination, she had signs of mild dehydration so intravenous antibiotics should be continued and we corrected her dehydration by IVF replacement as maintenance fluid + 3% deficit .
Progression
After that, she still had high grade fever until the 4th day of admission then her fever was resolved and clinical symptom was improved.
Moreover, she was able to eat a little so we still gave IV antibiotics until the 7th day of admission.
Hemoculture 20/12/50 : no growth
Progression DATE 20/12/50 21/12/50 22/12/50 23/12/50 24/12/50 25/12/50 26/12/50
Ceftriaxone Day 1 Day 7Day 2 Day 3 Day 4 Day 5 Day 6
37
38.6
40.4
39.3
39.8
36.0
37.3 37.0
38.2
38
41
40
39
35
36
Progression
While she was admitting , her mother complained that she had snoring. As a result, we investigated about “Obstructive sleep apnea” and we monitored overnight pulse oximetry.
The result is normal study.
Progression
Her status before discharge ; She had vital signs stable,
no fever, no diarrhea, no signs of dehydration, no convulsion and home medications. Therefore, she didn’t had any medications to prophylaxis for febrile seizure.
She had follow up at neurology clinic for 1 week.