Extern conference
January 3rd 2008
Case
A Thai 2 years 10 months old girl
 Chief Complaint


Generalized 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 & allergy
Sulfa group hypersensitivity
 No drug used continuously

Physical Examination




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
Vital Signs
Physical Examination
CVS
regular pulse, normal S1 S2, no murmur
 RS
Normal breath sounds, no adventitious
sounds
 Abdomen Soft, mild distention, not tender
No hepatosplenomegaly
Active 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 fL
Wbc 20,420 /mm3 N 86.9 % L 5.4 % M 5.3 % Eo 0.4 %
Platelet 240,000 /mm3

Peripheral blood smear:
normochromic microcytic RBCs
platelet : adequete
WBC : neutrophils predominate, no band form, toxic
granule 1+
Investigation

Urinalysis:
pH 5
Albumin neg
Rbc 0-1 /HPF
bacteria 1+
Sp.gr.1.015
Sugar neg
Acetone neg
Wbc 0-1 /HPF
Investigation
Na
K
 Cl
 HCO3
 Magnesium
 Corrected Ca

134
3.7
101
19
2.2
4.8
mmol/L
mmol/L
mmol/L
mmol/L
mg/dl
mg/dl
Discussion
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 siezure
Febrile seizure
Simple febrile seizure
Complex febrile seizure
 Lasts less than 15 minutes
 Lasts 15 minutes or longer
 Occurs once in a 24-hour
 Occurs more than once in a-
period
24-hour period
 Generalized
 Focal
 No previous neurologic
 Patient has known neurologic
problems
problems, such as cerebral
palsy
CNS infection
Meningitis
 Encephalitis
 Brain abscess

Intracranial hemorrhage
Subarachnoid hemorrhage
 Peri/intraventricular hemorrhage
 Subdural hemorrhage

Metabolic
Hypoglycemia
 Electrolyte imbalance

Hypocalcemia
 Hypomagnesemia
 Hypo/Hypernatremia

Shigellosis
History of acute gastroenteritis with moderate dehydration
 Toxin induced seizure

Diagnosis
 Complex febrile seizure
 Acute gastroenteritis with
moderate dehydration
Febrile seizure
 Marla J. Friedman et al. : Seizures in Children. Pediatr Clin N Am 2006;
53 (257– 277).
 Michelle D. Blumstein et al. : Childhood Seizures. Emerg Med Clin N
Am 2007; 25 (1061–1086).
Febrile seizure
Convulsion that occurs in association with a febrile
illness in children between 6 months and 5 years of
age in the absence of an identifiable cause.
 Febrile seizures are the most common type of seizure
in young children, with a 2% to 5% incidence of
children experiencing at least one seizure before the
age of 5 years.

Febrile seizure
Simple febrile seizure
Complex febrile seizure
 Lasts less than 15 minutes
 Lasts 15 minutes or longer
 Occurs once in a 24-hour
 Occurs more than once in a-
period
24-hour period
 Generalized
 Focal
 No previous neurologic
 Patient has known neurologic
problems
problems, such as cerebral
palsy
Febrile seizure
The peak age for febrile convulsions is between 18
and 24 months.
 The exact pathophysiology is unknown, but it seems
that a fever lowers the seizure threshold.
 Family history of febrile seizures present in 25% to
40% of children with febrile seizures.

When to do a lumbar puncture?
Investigation : LP

When to Do a lumbar puncture?
Every child < 1 year of age with a febrile convulsion.
 Presence of meningeal signs and symptoms.
 In case of doubt, if LP is not performed , the
paediatrician is advised to review the case within a few
hours.

HK J Paediatr (new series) 2002;7:143-151
When to do an imaging study?
Investigation : Imaging

Not necessary in most cases, but exceptions in a child
with
papilledema
 cranial nerve palsies (eg. 6th nerve palsy)
 other persisting focal neurological signs (eg.
hemiparesis)
 marked depression in mental status

HK J Paediatr (new series) 2002;7:143-151
Investigation : EEG
Rarely indicated in the management of a simple febrile
convulsion
 Complex febrile seizure

HK J Paediatr (new series) 2002;7:143-151
Investigation : Blood chemistry
Electrolytes and sugar in a child who is drowsy or
dehydration
 Toxicology screening if suspicious

HK J Paediatr (new series) 2002;7:143-151
Acute management : general








Same as other type of seizure
Maintain a clear airway (ABC!!!)
Give oxygen if available
Apply suction for nasal or oral secretions if facility available
Place the child in a semi-prone position
Protect the child from injury
Loosen clothing or remove excess clothing
Monitor vital sign
HK J Paediatr (new series) 2002;7:143151
Acute management : terminate
seizure
Benzodiazepines are the first drug of choice for
persistent seizure activity.
 Diazepam is the most common drug used

administer rectal diazepam 0.2-0.5 mg/kg/dose
 IV dose is 0.3 mg/kg/dose
 The 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;7:143151
Acute management
Observation for several hours after a febrile
convulsion
 Patients with a simple febrile seizure may be safely
discharged to home with parental reassurance and
seizure education.
 Follow up care

Hospital Admission : indication
Complex febrile seizure
 Suspicious of possibility of meningitis and
encephalitis
 Age < 18 months
 Anxious parents or inadequate home care

HK J Paediatr (new series) 2002;7:143151
Management : fever
Identify cause of fever
 Sponging 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

HK J Paediatr (new series) 2002;7:143151
Recurrent Febrile Convulsions
Management
Intermittent prophylaxis
 Continuous prophylaxis

HK J Paediatr (new series) 2002;7:143151
Management : intermittent
prophylaxis



Antipyretics and tepid sponge.
Diazepam prophylaxis seems to be effective in reducing the
recurrence rate.
Suggested doses for prophylaxis



0.5 mg/kg administered orally, or rectally every 12 hr whenever
the rectal temperature is > 38.5 ํC
Maximum of 4 consecutive doses
Side effects of diazepam

ataxia, lethargy and irritability
HK J Paediatr (new series) 2002;7:143151
Management : continuous
prophylaxis

Long-term Anticonvulsant Prophylaxis
Phenobarbitone or sodium valproate
 Currently Not advise due to

• No definitive evidence that anticonvulsants can
prevent later epilepsy
• Side effects of medications

Only use in highly selected case
• based on clinical circumstances and the judgement of
the benefit and its side effects
HK J Paediatr (new series) 2002;7:143151
Prognosis and outcome

Recurrence Risk of Febrile Convulsion
Risk of recurrence is~ 25- 30%
 Major predictor for recurrence of febrile convulsion
• Early age of onset
 Other predictors;
• Duration of fever before febrile seizure
• Temperature at onset of seizure
• Family history of febrile seizure, Prolonged seizure

HK J Paediatr (new series) 2002;7:143-151
Will the patient have epilepsy
in the future?
Risk factor for epilepsy


Children with febrile seizure have only a 1% to 2% lifetime risk
Risk factors for epilepsy





Family history of epilepsy
Complex febrile seizure
Underlying neurologic disorder
If two or more of these risk factors present, the future risk of
developing epilepsy is 10%.
General population have 0.5% to 1% lifetime risk of developing
epilepsy
Intellectual Deficit ?
Intellectual outcome is good
 Risk of Intellectual Deficit

Pre-existing neurological or developmental
abnormality
 Those who developed subsequent afebrile
convulsions

Parental education and reassurence
Reassurance and education is thus very important.
 Information to be provided to parents:

What should I do if my child has
a convulsion in the future?
What is febrile
• Stay calm.
convulsion?
• Look at your watch or a clock and
What should I do when my time
childthe convulsion.
• Do not try to restrain your child
develops fever in the future?
and do not put anything in their
mouth.
• Stay with your child and lay them
on their side.
• Loosen tight clothing from around
the neck and move objects away
that may cause injury.
Recurrence risk/Prognosis
• Arrange to see your local
doctor/general practitioner after
the convulsion has stopped.
Siriraj hospital : Clinical practice guildline
1.History taking
2.Physical examination
Patient with fever and seizure
(age 6 month – 5 years)
Assess cause of fever
Assess risk factor
•Age > 18 months
• Age
•Normal neurologicl exm
• Neurological PE
Simple febrile convulsion
• Type of seizure
If first seizure >>Reassure and
follow up
If recurrence >> Discuss about oral
diazepam prophylaxis
•Tepid sponge
•Antipyretics
•Treat infection
•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
Treat accordingly
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
Ceftriaxone
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
41
26/12/50
Day 7
40.4
39.8
40
39
38
39.3
38.6
38.2
37.0
37.3
37
36
36.0
35
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.

THANK YOU &
Happy new year !!!!