Simple and Complex Febrile Seizures (6 mos - 5 years)

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Simple and Complex Febrile Seizures (6 mos - 5 years)

Continued seizure activity?

Meets discharge criteria?

Note: Scheduled antipyretics do not decrease recurrence of simple febrile seizures

Prognosis: Patients with simple febrile seizures have only a very slight increase in their risk of developing epilepsy above the baseline risk of 1-2 percent for all children.

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Blood Culture (Aerobic and Anaerobic), Serum
Culture & Gram Stain, CSF
Glucose, CSF
Protein Total, CSF
Cell Count and Differential, CSF
Enterovirus PCR, CSF

IV fosphenytoin 15-20 mg/kg OR IV levetiracetam 40-50 mg/kg load, neurology consult, off pathway

Fosphenytoin injection
Levetiracetam injection

In otherwise well appearing children after seizure very few diagnostic tests have value. Appropriate, limited workup for source of fever should be guided by the history and physical. CBC, chemistries are rarely informative.

Inclusion Criteria
  • ≥ 1 seizure accompanied by fever (T >/= 38C) or parental report of fever within 24 hours
Exclusion Criteria
  • Toxic appearing
  • Previous afebrile seizure
  • Oncologic patient or Immunodeficiency
  • Trauma
  • VP shunt, previous neurosurgery, structural brain abnormality or intracranial mass
  • Ingestion
  • Developmental delay, complex genetic or metabolic disorder or any other history making a full neurologic exam complex

CSF concerning for meningitis/encephalitis?

Concern for source of fever by history?

Relevant, specific diagnostic testing and appropriate treatment

Simple Febrile Seizure

Labs indicate cause of seizure?

Off Pathway

Antibiotics, off pathway

Ceftriaxone injection
Vancomycin injection

Labs and neurology consult (concern for subclinical or nonconvulsive status), consider LP if not done

Complete Blood Count, Serum
Complete Metabolic Panel, Serum
Urinalysis with micro, Urine
Glucose by Meter, POC
Ammonia, Serum
Magnesium, Serum
Phosphorus, Serum
Urine Toxicology, Urine

Emergent MRI Brain if possible (or CT Head)

MRI Brain WO Contrast
CT Head WO Contrast

Concern for meningitis or encephalitis?

Admission criteria

  • Unstable clinical status and/or clinical infection requiring inpatient stay
  • Lumbar puncture strongly being considered, but unable to perform and provider not comfortable with discharge home
  • Social/family concerns
  • Barriers to safe return home
  • No reliable follow up

Discharge criteria

  • Reassuring vital signs
  • Normal neuro exam and mental status at baseline
  • Tolerating PO
  • Well-appearing
  • No social/family concerns
  • Reliable follow up in 24 hours
  • Parents comfortable and understand discharge plan
  • Provider comfortable with outpatient therapy

Requires urgent neuroimaging?

Complex Febrile Seizure

Remains altered or obtunded after seizure?

Actively seizing?

Meets discharge criteria?

  • Lumbar puncture
  • Consider admission if meeting admission criteria
  • Consider Pediatrics or Neurology consult

Indications for urgent neurology consultation

  • Persistent altered mental status
  • Abnormal neurological exam
  • Ongoing seizures
  • Status epilepticus / seizures refractory to appropriate benzodiazepine dosing x 2
  • Suspicion for subclinical status epilepticus
  • Abnormal neuroimaging (if obtained)

  • Consider admission if meeting admission criteria
  • Consider Pediatrics or Neurology consult

IV lorazepam 0.1 mg/kg OR intranasal midazolam 0.2 mg/kg (may repeat x1)

Midazolam 10mg/mL intranasal solution
Lorazepam injection

History/exam concerning for meningitis

  • 6-12 mos old and incomplete immunization status for HiB or Strep pneumo
  • Pretreated with antibiotics
  • Persistent altered mental status
  • Nuchal rigidity
  • Petechia
  • Bulging fontanelle
  • History or presence of poor feeding, vomiting, lethargy, irritability
  • Abnormal mental status cannot be adequately assessed on physical examination (eg, previous antiepileptic drug therapy)

Neurology consult

All of the following present?

  • < 15 minutes long
  • No recurrence within 24 hours
  • Generalized (no focal onset or features of seizure)
  • Return to baseline with no residual focal neurologic deficits

Reasons for urgent neurological imaging

  • Prolonged focal neurological deficit
  • Signs of infection of head or neck with potential for intracranial extension (eg, mastoiditis, sinusitis, orbital cellulitis)
  • Concern for localized intracranial infection
  • Concern for increased intracranial pressure

Home with education and appropriate treatment for source of fever if indicated

  • No bloodwork, LP, EEG, or neuroimaging in simple febrile seizure
  • Neuro consult/referral usually not indicated
  • Chronic antiepileptic drugs and rescue drugs (e.g. rectal diazepam) are not usually indicated

Home with education and PCP follow up

  • Recommendation to prescribe rectal diastat as abortive medication for children with a history of prolonged seizures
  • Prophylactic/chronic antiepileptics are not usually indicated

Neurology consult indications (not routinely needed for complex febrile seizure)

  • Persistent altered mental status
  • Persistent focal deficit
  • Status epilepticus / seizures refractory to appropriate benzo dosing x2

Outpatient neurology referral indications EEG and/or MRI (not routinely needed for complex febrile seizure)

  • More than 1 complex feature present (e.g. prolonged AND focal seizure)
  • Recurrent complex febrile seizures
  • Complex febrile seizure AND other risk factors for epilepsy:
    • History of parental non-febrile seizures
    • Baseline neurodevelopmental or neurological deficits/abnormalities (e.g. cerebral palsy, developmental delay, macro/microcephaly)
    • Previous traumatic brain injury or central nervous system infection
    • Previous episode of status epilepticus
    • Evidence of neuro-cutaneous syndrome (e.g. neurofibromatosis, tuberous sclerosis)

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