Neurology: Febrile Seizures Flashcards
Define what is meant by a febrile seizure [1]
A seizure x fever > 38C, without CNS infection (no meningitis or encephalitis) in children 6months - 5years
Name and describe the three categories of febrile seizures seen in children [3]
Simple febrile seizure:
- Less than 15 mins
- Generalised (epileptic discharge in brain is in two hemispheres, tonic-clonic)
- No recurrence within 24 hrs
- No postictal pathology
Complex:
- More than 15mins
- Focal
- May repeat
- Todd’s paresis may be present (loss of function of part of body for a few hours which then recovers)
Febrile status epilepticus
- More than 30 mins
How common are febrile seizures? [1]
What are risk factors for febrile seizures [4]
1/3 children have them
- 90% reoccur in first two years following the first one
Risk factors:
- < 18months age
- Fever less than 39
- FHx (first degree)
- Shorter duration of fever before seizure (< 1hr)
- Multiple seizures during same febrile illness)
Does febrile seizures mean a child has epilepsy? [1]
No - epilepsy is defined as episodes of unprovoked seizures
Which risk factors would increase the risk of epilepsy in children? [3]
Fx of afebrile seizures
Complex febrile seizures
Abnormal development / neurology
Describe the management of febrile seizures in the community [6]
- Time the length of the seizure (let the seizure run its course)
- Keep person away from hazards (cushion head, move hazards, make sure nothing hinders breathing)
- Don’t restrict movements
- Stay with them
- Make a record of what happened
- Place in recovery position after seizure
A febrile seizure has occurred.
When would you tell parents of a child to call an ambulance? [6]
First seizure
Not breathing / blue around lips
Seizure lasted more than 5 mins
Not responding after seizure stopped
Sustained an injury during seizure
What is the management of a febrile seizure if an inpatient? [3]
ABC
Treat underlying infection
If seizure > 5 mins - give benzodiazepine
In order the make a diagnosis of a febrile convulsion, other neurological pathology must be excluded. The differential diagnoses of a febrile convulsion are: [6]
- Epilepsy
- Meningitis, encephalitis or another neurological infection such as cerebral malaria
- Intracranial space occupying lesions, for example brain tumours or intracranial haemorrhage
- Syncopal episode
- Electrolyte abnormalities
- Trauma (always think about non accidental injury)
Describe the typical presentation of a febrile seizure [1]
A typical presentation is a child around 18 months of age presenting with a 2 – 5 minute tonic clonic seizure during a high fever.
NB: The fever is usually caused by an underlying viral illness or bacterial infection such as tonsillitis. Once a diagnosis of a febrile convulsion has been made, look for the underlying source of infection.
When would you consider a LP if a child is presenting with what appears to a be a febrile seizure
Lumbar puncture is important to consider to rule out meningitis, though only if there are indicative signs and/or symptoms, e.g. neck stiffness, Kernig and/or Brudzinski signs.
The American Association of Pediatrics details guidance on indication for lumbar puncture, including:
* Presence of indicative signs and/or symptoms, e.g. neck stiffness or Kernig and/or Brudzinski signs.
* If meningitis is suspected, blood cultures can be taken in addition to identify any bacteraemia.
* The child has not received all scheduled immunisations to date (in particular Haemophilus influenza B and pneumococcal vaccines).
* There is recent or current use of antibiotics.
How would you differentiate a febrile seizure to viral [3] and bacterial [3] meningitis
Viral meningitis may present with fever and seizures.
- However, other classic symptoms of meningitis including neck stiffness, nausea, and photophobia are unlikely to present with a febrile convulsion.
Bacterial meningitis:
- similarly involves additional symptoms including lethargy and rash. CSF analysis through lumbar puncture is also indicative, typically showing pleocytosis, elevated protein, and positive culture.
- Asking about any recent or current use of antibiotics is key, as they may mask symptoms of meningitis.
What is Dravet syndrome and how would you differentiate between a febrile covulsion?
Dravet syndrome
- previously known as severe myoclonic epilepsy of infancy, is a much more serious, lifelong condition, presenting with intractable seizures that are difficult to manage.
The first seizure often occurs with a fever, but it is distinct from febrile convulsions in that it commonly presents with additional issues including developmental delay.
- It is also unlikely to present after the first year of life.
If a febrile seizure lasts longer than 5 mins, NICE reccomends giving a benzodiazepine.
Which should you give and what is their route of a administration? [2]
If possible and if previously advised by a specialist, urgent management with benzodiazepines should be given, either buccal midazolam or rectal diazepam, as per NICE guidelines. Another dose can be given if the seizure does not abate within 10 minutes.
Describe what is meant by a breath holding spell in children [1]
What is the usual age for them? [1]
Breath holding spells are also known as breath holding attacks. They are involuntary episodes during which a child holds their breath, usually triggered by something upsetting or scaring them.
- Usually between 6-18months and most children out grow them by 4 or 5 years
What are the two types of breath holding spells in children? [2]
Describe how each present [4]
They are often divided into two types: cyanotic breath holding spells and pallid breath holding spells (also known as reflex anoxic seizures)
Cyanotic breath holding spells:
- occur when the child is really upset, worked up and crying
- After letting out a long cry they stop breathing, become cyanotic and lose consciousness.
- Within a minute they regain consciousness and start breathing.
- They can be a bit tired and lethargic after an episode.
Reflex anoxic seizures
- occur when the child is startled
- the vagus nerve sends strong signals to the heart that causes it to stop beating
- The child will suddenly go pale, lose consciousness and may start to have some seizure-like muscle twitching.
- Within 30 seconds the heart restarts and the child becomes conscious again.
- PM: Typical features, child goes very pale
falls to floor, secondary anoxic seizures are common, rapid recovery
Breath holding spells have been linked with []. Treating the child if they are [] can help minimise further episodes.
Breath holding spells have been linked with iron deficiency anaemia. Treating the child if they are iron deficiency anaemic can help minimise further episodes.
How do you manage breath holding spells? [1]
After excluding other pathology and making a diagnosis, educating and reassuring parents about breath holding spells is the key to management.
The mother of a 2-year-old girl arranges a telephone consultation to request your advice regarding febrile convulsions.
Unfortunately, her daughter was admitted to hospital a few days ago with her first febrile seizure, thought secondary to a viral upper respiratory tract infection. She describes it as a typical, tonic-clonic simple febrile convulsion lasting 2-3 minute with full recovery in around 30 minutes.
Her mother remembers being told that there is a risk of this happening again, however, recognised that the did not do anything really to treat it and she was discharged home.
She requests your advice regarding at what point an ambulance should be called if this happens again?
A further simple febrile convulsion lasting 4 minutes with recovery taking >30minutes
A further simple febrile convulsion lasting > 5 minutes
A further simple febrile convulsion lasting > 10 minutes
A further simple febrile convulsion lasting > 15 minutes
A further simple febrile convulsion within 48 hours
Parents should be advised to call an ambulance if a febrile convulsion lasts >5 minutes
