febrile seizure management

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Febrile Seizure Management

ObjectivesAt the conclusion of this article you should be able to:

Identify a febrile seizure.1.

Describe the pathophysiology of febrile seizures.2.

Identify the risk factors of febrile seizures.3.Identify the treatments for febrile seizures.4.

Case

You and your partner are called to a possible pediatric seizure in a residential

neighborhood at 2200 hours. A woman that introduces herself as the mother meets

you at the door crying hysterically. She leads you to a brightly lit room at the backof the house. As you follow, the woman explains that her 13 month old son Tommy

had some sort of “shaking fit” about 10 minutes ago. He was sleeping when she

heard a strange banging sound on the baby monitor. Upon entering Tommy’s room,she saw that his whole body was stiff and shaking. The mother states that she was

afraid to move or disturb the child and immediately called 911. The mother is unsure

of the duration of the seizure, but estimates it lasted less than six minutes. You

enter the room to see a small child lying on his back in a crib. The child’s breathing

is regular and shallow. You ask your partner to provide the patient with high flow

oxygen. Tommy does not respond to verbal commands but opens his eyes to painful

stimuli. The boy’s skin is pink, dry, and hot to the touch. Pupils are equal andreactive to light but sluggish. Cap refill is less than three seconds and pulse oximetry is 95 percent on room air. A rectal

temperature taken in the ambulance indicates that the boy’s temperature is 102F.

While collecting a patient history, the mother explains that she thought that Tommy caught a cold from one of the

children in his playgroup. Tommy had a fever and runny nose all day. The mother had been alternating betweenantipyretics for fever as suggested by the child’s pediatrician. The child has no history of febrile or other seizures.

However, the father remembers that he used to have seizures when he was a baby. Tommy has no other medical

history and does not take any medications on a daily basis.

In the back of the ambulance, you and your partner remove the boy’s clothes down to the diaper to aid in cooling.

Tommy weighs about 15 kg. You administer 150mg liquid children’s acetaminophen PO as per protocols for fever. Youand your partner start a 24g IV in Tommy’s left hand and flow NS TKO. The boy rests calmly in the mother’s lap while

you transport him to the emergency department for further evaluation. Vitals remain stable during transport. After a

series of tests completed in the ED, Tommy is diagnosed with febrile seizures and admitted for overnight evaluation todetermine the cause of infection.

Introduction and EpidemiologySeizures are temporary changes in brain function that can cause involuntary changes in body movement, sensation,

awareness, or behavior.2 A seizure results from alterations in neuronal membrane permeability to potassium and

sodium ions.1 This increased permeability to the specific ions lowers the depolarization threshold of the neurons

allowing them to release electrical activity more easily.2 Normal brain function requires an orderly, organized, and

coordinated discharge of electrical impulses that enable the brain to communicate with the spinal chord, nerves, and

muscles. A change in the neuronal depolarization threshold alters the balance of orderly and coordinated electrical

discharge, often resulting in seizure activity.1 Depending on the part of the body affected, seizures are classified as

generalized or partial. Generalized seizures affect large areas of both sides of the brain. Partial seizures affect only oneside and usually a specific part of the brain.

Partial seizures may be simple or complex. A person is completely conscious and aware of the surroundings during asimple partial seizure while one’s consciousness is impaired during a complex partial seizure. Generalized seizures

cause a loss of consciousness and random muscle contractions.

Febrile seizures are convulsions brought on by a fever in small children between the ages of six months and six years

without evidence of intracranial infection or defined cause.6 Meningitis has to be eliminated as the primary cause of the

seizure by the emergency department to truly diagnose a patient with febrile seizures. Febrile seizures typically occur

at the onset of an illness. Although the risk of a seizure increases with higher fevers, half of all episodes occur at

temperatures under 40C / 104F.2

Febrile seizures are usually benign but can cause considerable parental anxiety. It is disputable whether a febrile

seizure has to be regarded as an epileptic disorder or not. Contributing to the dispute is the fact that most children with

febrile seizures outgrow them with no lasting ill effects.6 In fact, most children grow into adulthood without future

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seizure disorders. There is no evidence that febrile seizures cause brain damage. Large studies have found that children

with febrile seizures have normal school achievement and perform as well on intellectual tests as their siblings who

don't have seizures.4 Even in the rare instances of very prolonged seizures lasting more than one hour, most children

recover completely. Therefore, treating the patient usually requires supportive care and delicate management of the

parents or guardians.

PathophysiologyFebrile seizures are the most common type of seizure encountered in infants and small children. Studies have led to the

division of febrile seizures into two groups: simple febrile seizures and complex febrile seizures.5 Simple febrile seizures

are generalized seizures that occur with the initial temperature elevation at the onset of illness and last less than 15

minutes.5 Children with simple febrile seizures usually lack the postictal stupor that follows seizures of other etiologies.

Complex febrile seizures are prolonged seizures that last longer than 15 minutes, recur more than once in 24 hours, or

have focal motor symptoms only.5 These seizures are associated with a higher risk of developing epilepsy later. Unlike

with simple febrile seizures, children that experience complex seizures should be expected to have a postictal stupor

common to seizure disorders. Among the five percent of children with febrile seizures, about 75 percent have simple

seizures and 25 percent have complex seizures.6

Viral illnesses are the predominant cause of febrile seizures. Recent literature documented the presence of human

herpes simplex virus (HHSV-6) as the etiologic agent in about 20 percent of a group of patients presenting with their

first febrile seizures.5 Gastroenteritis has also been associated with febrile seizures.

Risk FactorsFor a child between the ages of six months and six years, certain factors raise the risk of a febrile seizure. Presence of

two or more of the following risk factors increases the probability of a first febrile seizure to about 30 percent.6

The firstand most obvious risk for a febrile seizure is a high internal temperature. As mentioned previously, most febrile

seizures occur with a core temperature at or below 40C/ 104F.6 There is no data to support the theory that a rapid rise

in temperature is a cause of febrile seizures.3 However, physicians tend to teach this to parents, pointing out that little

research has been completed to confirm or deny the theory. Second, a family history of febrile seizures is highlyindicative of possible seizures and carries a 25 percent risk. Genetic predisposition clearly contributes to the occurrence

of febrile seizures, but neither a specific position of a gene on a chromosome nor a specific pattern of inheritance has

been described.5 The mode of inheritance is likely to vary between families and may be multifactorial. Statistically,

children that attend daycare on a regular basis have an increased incidence of febrile seizures.6 Lastly, mental andphysical developmental delays raise the risk of possible seizures.

Approximately 30 percent of children who have one febrile seizure have a second seizure during another febrile illness.5

Children at risk for recurrent febrile seizures have certain traits in common. A family history of a febrile seizure in a first

degree relative such as a parent or sibling raises the chance of a second seizure. The younger the child is at the time of the first febrile seizure, the higher the chance of a future febrile seizure. If the child is under 12 months at the time of

the first febrile seizure, then he or she has a 50 percent probability of having another febrile seizure within 12 months.6

With children older than 12 months at the time of their first simple febrile seizure, the probability of having another

febrile seizure decreases to 30 percent. A relatively low fever at the time of the first seizure indicates the possibility of

future occurrences. The lower the fever is at the time of the seizure, the lower the seizure threshold of the child. Also, abrief duration between the onset of fever and the initial seizure raises the possibility of another febrile seizure. This

factor also indicates that the patient has a low seizure threshold. Patients with all four risk factors have greater than a

70 percent chance of recurrence.5 Patients with no risk factors have less than a 20 percent chance of recurrence. 5

Risk factors for epilepsy later in life include complex febrile seizure, family history of epilepsy or neurologicalabnormality, and developmental delay. Patients with two risk factors have up to a 10 percent chance of developing

afebrile seizures later in life. Febrile seizures may have a role in the development of some types of epilepsy,

particularly temporal lobe epilepsy where many patients have a history of febrile seizures in childhood. The nature of this relationship is still under investigation. At this time there is no way to identify which children will develop temporal

lobe epilepsy, or whether any form of treatment can prevent its occurrence. Children with febrile seizures have a 2.4

percent incidence of epilepsy compared with a 1.2 percent incidence in the general population.6

Patient HistoryThe cornerstone of the exam of a possible febrile seizure is a careful and detailed history. The responsibility of one EMS

crewmember is collecting a thorough patient and family history from a parent or guardian. Important components of a

patient history include:

Occurrence and number of previous seizures.1.Number of seizures in current episode and how close together.2.

Description of seizure activity: generalized, focal motor, or localized.3.

Vomiting during the seizure?4.

Condition of the patient when found: postictal, lethargic, crying.5.


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Recent or past history of head trauma: fall, motor vehicle accident, or abuse.6.

Recent history of fever, illness, headache, or stiff neck.7.

Past medical history- diabetes, heart disease, stroke, developmental delay, or surgeries.8.

Potential for ingestion of toxins or other household objects.9.

Medications and compliance with anticonvulsant medications if applicable.10.

The evaluation of a child with febrile seizures should be aimed at excluding serious conditions that may be present. If not readily excluded by the history and exam, the EMS crew should consider seizure causes such as hypoglycemia,

hypoxia, or toxins. The population that is prone to febrile seizures is also prone to ingestion of medicines and household

products. The EMS crew must quickly rule out accidental ingestion because immediate treatment is necessary for such

life-threatening emergencies. Multiple other conditions can lead to seizure activity as well. However, identifying theexact cause of the seizure is less important than recognizing whether the condition is reversible with therapy. A detailed

patient history may not be directly beneficial to the EMS crew, but the information can be essential to patient care inthe emergency department.

Physical Examination and ManagementMost febrile seizure patients are not actively seizing by the time EMS crewmembers arrive at the scene. As with any

physical examination, begin by evaluating the ABC’s: airway, breathing, and circulation. Is the patient breathing? If not,

try manual airway positioning and suctioning of the airway. Is the respiratory rate and depth adequate? Does thepatient have adequate perfusion? Is the capillary refill less than three seconds? Often, administration of high flow

oxygen alone will increase respiratory rate and improve perfusion. If not, then airway adjuncts and a bag valve mask

should be used to maintain a good airway and circulatory support.

The paramedic should be alert to signs of traumatic injury to the head, neck, tongue or mouth. Such injuries may occur

before or during the seizure activity. Other components of the physical examination are:

Level of consciousness- postictal, evaluate for age and developmental level.1.

Pupil reaction to light.2.

Motor and sensory evaluation.3.

Fever and other vital signs.4.Cardiac dysrhythmias or other notable abnormalities.5.

Bowel and bladder incontinence.6.

EMS crews offer the first line of treatment for possible febrile seizure patients. Often, overwhelmed and panicky parents

call 911 for treatment of pediatric febrile seizures. First, patients with active seizures should be treated with airway

management, high flow oxygen, supportive care, and anticonvulsants. Anticonvulsants used often in EMS to control

active seizures are diazepam, midazolam,2 and alprazolam. Possible side effects of anticonvulsant therapy include

respiratory depression and hypotension. Approximately 40 percent of patients will develop side effects of ataxia,

lethargy, or irritability. Consequently, the paramedic should start with the minimum dose of anticonvulsant available.More medication can be administered in following doses as necessary. The EMS crew should be alert for these

complications.

Patients who are postictal should receive high flow oxygen, supportive care, and antipyretics as appropriate. The

common antipyretics utilized in pediatric medicine are acetaminophen and ibuprofen.2 Pediatric dosage for

acetaminophen is 10-15mg/kg PO/PR every four to six hours, but not to exceed five doses per day. Ibuprofen pediatric

dosage is 5-10mg/kg/dose PO every six to eight hours, but not to exceed 40mg/kg per day. Patients presenting withhistory and physical examination findings consistent with a simple febrile seizure should have frequent neurological

examinations to monitor mental status. All pediatric patients who have seizure activity should be transported to the ED

for further evaluation by a physician.

Family Management

A key responsibility of the EMS crew is the management and education of the parents or guardians of the febrile seizure

patient. The parents are often frightened and overwhelmed. The crew should offer security and confidence. Inform

parents that these dramatic events do not indicate future dysfunction or disease. Most of the time, a febrile seizure

occurs the first day of an illness. Often, a febrile seizure occurs before parents realize that their child is ill. Reassure the

family that febrile seizures are common with viral illnesses and that they did the right thing by calling for emergency

care.

Educate the family about what to do to care for their child if another seizure occurs. If the child is susceptible to febrile

seizures, it may be possible to prevent these seizures by taking quick action to control fever when the child has an

illness. By giving acetaminophen or ibuprofen at the first indication of fever, one may reduce the chance of a febrile

seizure. The family can also control fever by making sure the child drinks plenty of fluids and sleeps covered loosely.

The old wives’ tale that refers to sweating out a fever is incorrect and dangerous. Remind the parents or guardians not

to give aspirin to children. Aspirin may trigger a rare but potentially fatal disorder known as Reye's syndrome.Reinforce that it is not necessary to lower your child's fever to stop a febrile seizure. Make sure the family understands

not to give a child fever medications during a seizure. For the same reason, the child should not be placed in a cooling


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tub of water. Most febrile seizures stop on their own within five minutes. Some key steps that the family can use to help

a child during a seizure:

Place the child on his or her side, in a safe place where he or she won't fall.1.Stay close by to watch and comfort your child.2.

Remove any hard or sharp objects near your child.3.

Loosen any tight or restrictive clothing.4.Don't restrain the child or interfere with your child's movements.5.

Don't attempt to put anything in your child's mouth.6.

Try to time the seizure with a watch or clock7.

Note which part of the child's body begins to shake first8.

Parental anxiety or other factors may cause a child to be placed on long-term anticonvulsant medicine. Whenadministered on a daily basis, two medications have demonstrated some effectiveness in preventing recurrent febrile

seizures: phenobarbital and valproate. Phenobarbital can cause adverse behavioral effects in about 40 percent of

children and an allergic reaction. Valproate is associated with liver failure plus injury to other organs such as the bonemarrow, kidneys, and pancreas. Despite parental intentions, these medications seem to have more risks than benefits.

Consequently, doctors rarely prescribe these prevention medications for febrile seizures because most are harmless

incidents that children outgrow without any problems.

Conclusion

Febrile seizures are convulsions brought on by a fever in small children between the ages of six months and six years

without evidence of intracranial infection or defined cause.6 Febrile seizures are a common and usually benign childhood

occurrence. While antipyretics are the only treatment necessary for most children, for a small number the use of anticonvulsants may be necessary. The primary EMS responsibilities when treating febrile seizure patients are the

collection of a detailed history and supportive care. Delicate management of the patient or guardian is essential.

Author Lisa O'Neill Copyright © CE Solutions. All rights reserved.

Bibliography

Bledsoe, B et al. Essentials of Paramedic Care. Pearson Education, Inc. Upper Saddle River, NJ 2003.1.

Sanders, M. Mosby’s Paramedic Textbook: Revised Second Edition. Mosby, Inc. St Louis, MS, 2001: 930-934,1225-1226,1255-1257.2.

Vastergaard, Mogens et al. MMR Vaccination and Febrile Seizures: Evaluation of Susceptible Subgroups and Long-term Prognosis. JAMA.

2004, 292: 351-357.

3.

Beers, Mark et al. The Merck Manual of Medical Information: Second Home Edition. Merck and Co, Inc. Whitehouse Station, NJ, 2005.4.

Goldstein, MA. Infectious states: Managing epilepsy and co-existing disorders. Boston: Butterworth-Heinemann; 2002: 83-133.5.

Offringa, M et al. Risk factors for seizure recurrence in children with febrile seizures: A pooled analysis of individual patient data from five

studies. J Pediatrics 1994; 124(4): 574-584.

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febrile seizure management

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