Andi Marmor, MD, MSEd Associate Professor, Pediatrics University of California, San Francisco
Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments
Febrile seizures: Who need further workup? Afebrile seizures: Who needs imaging? Status epilepticus: Most effective treatments
Tesla is a previously healthy 16 mo girl BIB ambulance after she “had a seizure” Fell to the ground while playing and became stiff
and non‐responsive, eyes rolled back, for 30 seconds – 911 called
No apnea or focal movements noted Sleepy but responsive in the ambulance, T = 37.9
A. B. C. D. E.
Febrile to 39.0, VS otherwise WNL Neuro: Moving all extremities, fussy but consolable by father Initially sleepy but becoming more and more alert as you observe her No source for fever is apparent on history/PE
Obtain blood, urine and CSF cultures Admit for neurologic evaluation Obtain a head CT or MRI Obtain a stat EEG Discharge when at neurologic baseline
Etiology: NOT fever! Cytokines!
“Simple” Febrile Seizure Short, generalized, isolated Generally considered benign
“Complex” Febrile Seizure Longer OR focal OR recurrent May be more concerning? HHV-6: Roseola
NO: Rates of SBI in SFS similar to age‐ matched febrile children Meningitis? No cases of meningitis in the absence of focal
signs/symptoms in series’ of SFS/CFS
However, meningitis can present with fever and seizure…. Failure to return to normal MS/Focal neuro exam Febrile convulsive status
Kimia, 2010; Fletcher 2013
Your patient comes back within 24 hours with another short, generalized seizure Now what would you do? Even children with CFS are at very low risk for SBI/meningitis LP can be done in select children with concerning features Febrile status, focal/abnormal neuro exam, recent
antibiotics Kimia, 2010; Fletcher 2013
EEG: Not useful in predicting recurrence or epilepsy, even in complex febrile seizures Anticonvulsants/antipyretics : do not alter course
Confirm child has no neurologic abnormality Identify and treat source for fever, by age Further workup based on H and P LP for convulsive status, abnormal neuro exam
Consider LP for Recent antibiotics, several days of fever before sz
Consider referral to neuro for Focal seizure or recurrent complex seizure
DC when back at neurologic baseline Educate on recurrence: 10‐50% Younger age, family history, complex seizure,
lower temperature
Treat fevers appropriately for comfort only
Leaf is a 2 yo boy BIB ambulance after a generalized, tonic clonic seizure Given rectal diazepam seizure has ceased
No prior seizures, developmentally normal Deny trauma, recent illness, travel, change in diet.
He is afebrile, sleepy but arousable Pushes you away purposefully and symmetrically,
and knows his name and age
A. B. C. D. E.
Head CT Head MRI Complete H and P CBC and electrolytes Lumbar puncture
Yield of imaging in children with a first‐time afebrile seizure is very low 8% in one study (Sharma, 2003), with
