Febrile Seizures in Emergency Medicine Workup

  • Author: Nooruddin R Tejani, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Aug 31, 2011
 

Laboratory Studies

In children under the age of 5 with complex febrile seizures, over one-third of experienced pediatric emergency physicians would do extensive workup, nearly half would admit, but variability exists in the approach to optimal management of patients with CFS. Past studies support more aggressive workup for patients under the age of 18 months, but future prospective studies on this subject are warranted.[25]

  • Routine laboratory studies usually are not indicated for febrile seizure unless they are performed as part of a search for the source of a fever.
  • Electrolytes assessments are rarely helpful in the evaluation of febrile seizures.[6]
  • Patients with febrile seizures have an incidence of bacteremia similar to patients with fever alone.[26]
Next

Imaging Studies

  • A CT scan usually is not necessary in the evaluation of a child with a first simple febrile seizure.
  • A CT scan should be considered in patients with complex febrile seizures. However, a study by Teng et al analyzed data in 71 children with first complex febrile seizure.[27] Fifty-one (72%) had a single complex feature (20 focal, 22 multiple, and 9 prolonged), and 20 (28%) had multiple complex features. None of the 71 patients (1-sided 95% confidence interval, 4%) had intracranial pathologic conditions that required emergency neurosurgical or medical intervention. Forty-six had normal acute scans; the rest were normal on clinical follow up without a scan. The confidence interval means that this study cannot exclude a risk of intracranial pathology of 4% or less.
Previous
Next

Other Tests

  • An electroencephalogram (EEG) usually is not necessary in the routine evaluation of a child with a first simple febrile seizure.
Previous
Next

Procedures

  • Lumbar puncture
    • Controversy exists regarding the need for a lumbar puncture in a child presenting with a simple febrile seizure.
    • Lumbar puncture is not needed for young children with first simple febrile seizure.[28]
    • Certainly, meningitis can present with a seizure, although the seizure usually is not the only sign of meningitis. Patients who have a first-time febrile seizure and do not have a rapidly improving mental status (short postictal period) should be evaluated for meningitis.
    • Several reviews of the medical literature report less than 5% incidence of meningitis in children presenting with seizures and fever.
    • Risk factors for meningitis in patients presenting with seizure and fever include the following:
      • A visit to a healthcare setting within the previous 48 hours
      • Seizure activity at the time of arrival in the ED
      • Focal seizure, suspicious physical examination findings (eg, rash, petechiae) cyanosis, hypotension, or grunting
      • Abnormal neurologic examination
    • In 1996, the American Academy of Pediatrics (AAP) recommended that a lumbar puncture be strongly considered in patients younger than 12 months presenting with fever and seizure.[2] The AAP also recommended that a lumbar puncture be considered in patients aged 12-18 months. A lumber puncture is not routinely necessary in patients older than 18 months. This recommendation is conservative, but it takes into account the difficulty in recognizing meningitis in infants and young children and the range of experience in the evaluation of pediatric patients among healthcare providers.
Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

Nooruddin R Tejani, MD  Assistant Professor, Department of Emergency Medicine, SUNY Health Sciences Center Brooklyn; Director, Pediatric Emergency Medicine, Downstate Medical Center

Nooruddin R Tejani, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Debra Slapper, MD  Consulting Staff, Department of Emergency Medicine, St Anthony's Hospital

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, William T Zempsky, MD, to the development and writing of this article.

References

  1. Consensus statement. Febrile seizures: long-term management of children with fever-associated seizures. Pediatrics. Dec 1980;66(6):1009-12. [Medline].

  2. [Guideline] Guidelines for epidemiologic studies on epilepsy. Commission on Epidemiology and Prognosis, International League Against Epilepsy. Epilepsia. Jul-Aug 1993;34(4):592-6. [Medline].

  3. Matsuo M, Sasaki K, Ichimaru T, Nakazato S, Hamasaki Y. Increased IL-1beta production from dsRNA-stimulated leukocytes in febrile seizures. Pediatr Neurol. Aug 2006;35(2):102-6. [Medline].

  4. Gatti S, Vezzani A, Bartfai T. Mechanisms of fever and febrile seizures: putative role of the interleukin-1 system. In: Baram TZ, Shinnar S. Febrile Seizures. San Diego, Ca: Academic Press; 2002:169-88.

  5. Haspolat S, Mihci E, Coskun M, Gumuslu S, Ozben T, Yegin O. Interleukin-1beta, tumor necrosis factor-alpha, and nitrite levels in febrile seizures. J Child Neurol. Oct 2002;17(10):749-51. [Medline].

  6. [Guideline] American Academy of Pediatrics. Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: the neurodiagnostic evaluation of the child with a first simple febrile seizure. Pediatrics. May 1996;97(5):769-72; discussion 773-5. [Medline].

  7. Millichap JG, Millichap JJ. Role of viral infections in the etiology of febrile seizures. Pediatr Neurol. Sep 2006;35(3):165-72. [Medline].

  8. Kwong KL, Lam SY, Que TL, Wong SN. Influenza A and febrile seizures in childhood. Pediatr Neurol. Dec 2006;35(6):395-9. [Medline].

  9. Audenaert D, Van Broeckhoven C, De Jonghe P. Genes and loci involved in febrile seizures and related epilepsy syndromes. Hum Mutat. May 2006;27(5):391-401. [Medline].

  10. Iwasaki N, Nakayama J, Hamano K, Matsui A, Arinami T. Molecular genetics of febrile seizures. Epilepsia. 2002;43 Suppl 9:32-5. [Medline].

  11. Hirose S, Mohney RP, Okada M, Kaneko S, Mitsudome A. The genetics of febrile seizures and related epilepsy syndromes. Brain Dev. Aug 2003;25(5):304-12. [Medline].

  12. Nakayama J, Arinami T. Molecular genetics of febrile seizures. Epilepsy Res. Aug 2006;70 Suppl 1:S190-8. [Medline].

  13. Verity CM, Butler NR, Golding J. Febrile convulsions in a national cohort followed up from birth. I--Prevalence and recurrence in the first five years of life. Br Med J (Clin Res Ed). May 4 1985;290(6478):1307-10. [Medline].

  14. Hauser WA. The prevalence and incidence of convulsive disorders in children. Epilepsia. 1994;35 Suppl 2:S1-6. [Medline].

  15. Chung B, Wat LC, Wong V. Febrile seizures in southern Chinese children: incidence and recurrence. Pediatr Neurol. Feb 2006;34(2):121-6. [Medline].

  16. Vestergaard M, Pedersen MG, Ostergaard JR, Pedersen CB, Olsen J, Christensen J. Death in children with febrile seizures: a population-based cohort study. Lancet. Aug 9 2008;372(9637):457-63. [Medline].

  17. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. Nov 4 1976;295(19):1029-33. [Medline].

  18. Berg AT, Shinnar S. Unprovoked seizures in children with febrile seizures: short-term outcome. Neurology. Aug 1996;47(2):562-8. [Medline].

  19. van Esch A, Steyerberg EW, van Duijn CM, Offringa M, Derksen-Lubsen G, van Steensel-Moll HA. Prediction of febrile seizures in siblings: a practical approach. Eur J Pediatr. Apr 1998;157(4):340-4. [Medline].

  20. Bethune P, Gordon K, Dooley J, Camfield C, Camfield P. Which child will have a febrile seizure?. Am J Dis Child. Jan 1993;147(1):35-9. [Medline].

  21. Vestergaard M, Basso O, Henriksen TB, Ostergaard JR, Olsen J. Risk factors for febrile convulsions. Epidemiology. May 2002;13(3):282-7. [Medline].

  22. Offringa M, Bossuyt PM, Lubsen J, Ellenberg JH, Nelson KB, Knudsen FU. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data from five studies. J Pediatr. Apr 1994;124(4):574-84. [Medline].

  23. Waruiru C, Appleton R. Febrile seizures: an update. Arch Dis Child. Aug 2004;89(8):751-6. [Medline].

  24. Berg AT, Shinnar S, Darefsky AS, Holford TR, Shapiro ED, Salomon ME. Predictors of recurrent febrile seizures. A prospective cohort study. Arch Pediatr Adolesc Med. Apr 1997;151(4):371-8. [Medline].

  25. Sales JW, Bulloch B, Hostetler MA. Practice variability in the management of complex febrile seizures by pediatric emergency physicians and fellows. CJEM. May 2011;13(3):145-9. [Medline].

  26. Chamberlain JM, Gorman RL. Occult bacteremia in children with simple febrile seizures. Am J Dis Child. Oct 1988;142(10):1073-6. [Medline].

  27. Teng D, Dayan P, Tyler S, Hauser WA, Chan S, Leary L. Risk of intracranial pathologic conditions requiring emergency intervention after a first complex febrile seizure episode among children. Pediatrics. Feb 2006;117(2):304-8. [Medline].

  28. Kimia AA, Capraro AJ, Hummel D, Johnston P, Harper MB. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. Jan 2009;123(1):6-12. [Medline].

  29. McIntyre J, Robertson S, Norris E, Appleton R, Whitehouse WP, Phillips B, et al. Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet. Jul 16-22 2005;366(9481):205-10. [Medline].

  30. Bhattacharyya M, Kalra V, Gulati S. Intranasal midazolam vs rectal diazepam in acute childhood seizures. Pediatr Neurol. May 2006;34(5):355-9. [Medline].

  31. Sadleir LG, Scheffer IE. Febrile seizures. BMJ. Feb 10 2007;334(7588):307-11. [Medline].

  32. van Stuijvenberg M, Derksen-Lubsen G, Steyerberg EW, Habbema JD, Moll HA. Randomized, controlled trial of ibuprofen syrup administered during febrile illnesses to prevent febrile seizure recurrences. Pediatrics. Nov 1998;102(5):E51. [Medline].

  33. [Guideline] Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures American Academy of Pediatrics. Febrile seizures: clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. Jun 2008;121(6):1281-6. [Medline].

  34. Strengell T, Uhari M, Tarkka R, Uusimaa J, Alen R, Lautala P. Antipyretic agents for preventing recurrences of febrile seizures: randomized controlled trial. Arch Pediatr Adolesc Med. Sep 2009;163(9):799-804. [Medline].

  35. Autret E, Billard C, Bertrand P, Motte J, Pouplard F, Jonville AP. Double-blind, randomized trial of diazepam versus placebo for prevention of recurrence of febrile seizures. J Pediatr. Sep 1990;117(3):490-4. [Medline].

  36. Rosman NP, Colton T, Labazzo J, Gilbert PL, Gardella NB, Kaye EM. A controlled trial of diazepam administered during febrile illnesses to prevent recurrence of febrile seizures. N Engl J Med. Jul 8 1993;329(2):79-84. [Medline].

  37. Verity CM, Golding J. Risk of epilepsy after febrile convulsions: a national cohort study. BMJ. Nov 30 1991;303(6814):1373-6. [Medline].

  38. Berg AT. Febrile seizures and epilepsy: the contributions of epidemiology. Paediatr Perinat Epidemiol. Apr 1992;6(2):145-52. [Medline].

  39. Verity CM, Butler NR, Golding J. Febrile convulsions in a national cohort followed up from birth. II--Medical history and intellectual ability at 5 years of age. Br Med J (Clin Res Ed). May 4 1985;290(6478):1311-5. [Medline].

  40. Verity CM, Greenwood R, Golding J. Long-term intellectual and behavioral outcomes of children with febrile convulsions. N Engl J Med. Jun 11 1998;338(24):1723-8. [Medline].

  41. Tarkka R, Paakko E, Pyhtinen J, Uhari M, Rantala H. Febrile seizures and mesial temporal sclerosis: No association in a long-term follow-up study. Neurology. Jan 28 2003;60(2):215-8. [Medline].

  42. Nelson KB, Ellenberg JH. Predictors of epilepsy in children who have experienced febrile seizures. N Engl J Med. Nov 4 1976;295(19):1029-33. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.