Paediatrics: Seizures: management

Seizures: management

First unprovoked seizure

·  History: a full account of personal, social, and family history should be obtained.

·  Examination: perform a thorough examination looking for markers of neurological diseases, particularly skin and dysmorphism.

·  Electroencephalography (EEG): there is debate as to whether an EEG should be obtained. The current opinion is that, in most children, it is unlikely to influence management. Few specialists would start therapy at this point whatever the EEG showed. With expert neurophysiology a more accurate prognosis may be given, which in turn may influence therapy.

·  Imaging: MRI is not indicated after a single seizure alone. However, if abnormality is found on physical examination then MRI is very important to exclude a space-occupying lesion.

Febrile seizures

These can occur in infants or small children. Most last a minute or two, but it can be just a few seconds. Others last for more than 15min.

·  Typically, these children have no prior neurological disease or focal deficits on examination. Here are some key facts about febrile seizures.

·  They occur in up to 4% of all children, generally between the ages of 6mths and 6yrs (although it is unusual to have one’s first episode when aged >4yrs).

·  These children may have a temperature ≥39*C, however the temperature may have become normal by the time it is measured.

·  The seizure tends to occur during the first day of fever.

·  Children prone to febrile seizures are not considered to have epilepsy.

·  Recurrence risk of seizures is 35% over lifetime; 25% during the next 12mths.

·  The vast majority of febrile seizures are harmless.

·  95–98% of children who have experienced febrile seizures do not go on to develop epilepsy.

·  Children who have febrile seizures that are lengthy, affect only part of the body, recur within 24hr, or who have neurological abnormalities have a higher incidence of subsequent epilepsy.

Categorization

·  Simple febrile seizures (typical): generalized tonic–clonic activity lasting <15min with associated fever.

·  Complex febrile seizures (atypical): these occur in up to 15% of cases and are characterized by focal seizure activity, or prolonged seizure longer than 15min, or multiple seizures within a day.

·  Convulsive seizures that occur in a child with no neurological problems, in the context of an intercurrent infection, even without a recorded fever, are normally classified as febrile.

Management of febrile seizure

Safety

·Move any danger away from the child and consider their privacy

·Place the child on a protected surface on their side

·It is good practice to note the time

Assistance

·The family should call for help if unfamiliar with febrile seizures

·Then call ambulance

Treatment

·If the seizure lasts >10min, the child should be treated for status epilepticus

·Once the seizure has ended, the child should be assessed for the source of the fever, investigated, and treated appropriately

·Consider admission and observation, especially if this is the first episode

Meningitis?

·Consider meningitis if the child shows symptoms of stiff neck, extreme lethargy more than 4hr post-seizure, abundant vomiting, or is <12mths old

·If there is concern perform a lumbar puncture as long as the child is not encephalopathic

Seizure prevention and home care

·There is poor evidence to support interventions to prevent febrile seizures

·Parents should give standard antipyretics early in any febrile illness

·  Parents should get expert advice if a previous seizure lasted >10min