Febrile Seizure Management
1. Define what a febrile seizure is
2. Refer to national standards and guidelines for Pediatric Seizure Management including Febrile seizures
3. Refer to this study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6210946/
4. Refer to this study https://www.mayoclinic.org/diseases-conditions/febrile-seizure/diagnosis-treatment/drc-20372527
5. Review medications used to treat febrile seizures
6. Review treatment modalities
7. Review Pediatric IO placement sites and techniques
- Seizure caused by a sudden dramatic rise (spike) in body temperature1
- Most common in infants and children
- Unrelated to neurologic condition, rather caused solely by change in temperature
- Do not typically cause lasting problems or harm to the child
- Symptoms:
- Loss of consciousness
- Full body shaking/shaking or jerking of the arms and legs
- Fever above 100.4 F (sudden rise rather than gradual - usually)
- Possible with low grade fevers
- Simple febrile seizure:
- Non recurrent
- Last seconds up to 15 min
- Not focused to one region of the body
- Complex febrile seizure:
- >15 min
- Recurrent within 24 hrs
- One side of the body
- Treatment
- Place child on his/her side
- Time seizure
- Remove objects that could incur child or become restrictive (clothing)
- Leave child alone
- Highest risk is 6mo - 5 yrs2
- Possible for fever to develop after the seizure occurs
- Usually accompany other illness (typically illnesses that cause fevers)
- Recurrence is most common in children who had their first seizure before 18 mo of age
- Family history of febrile seizure
- Ibuprofen and acetaminophen are often given to manage fever to prevent initial seizure
- Studies show that these medications will likely not prevent a recurring seizure for a child who has already seized
- Studies of prehospital treatment for seizures has shown that pts with witnessed seizure who ARE NOT actively seizing should receive limited intervention3
- Postictal phase:
- Supplemental O2
- Possible IV line (only if medications or fluid is needed, or pt is at risk for another seizure)
- ETCO2
- NPA
- Further airway intervention if pt has respiratory depression unaffected by BVM assistance
- SPO2
- Position of comfort
- CBG monitoring
- For pts actively seizing on EMS arrival (febrile status epilepticus)
- FSE occurs in about 10% of febrile seizures
- #1) IM injection of midazolam- .2mg/kg should be primary treatment for actively seizing child
- #2) Initial dose of IN and buccal midazolam is .2 mg/kg
- #3) IV midazolam and lorazepam is .1mg/kg
- Children not seizing can be transported without meds
- Once seizure is controlled, CBG should be monitored
- Postictal phase:
-
- Potential risk factors for FS include4:
- Viral illness
- Specific vaccinations
- Genetic predisposition
- Children’s developing nervous system under stress of a fever
- Potential risk factors for FS include4:
- Vaccinations associated with febrile seizure5:
- CDC states the following vaccines lead to a slightly increased risk of febrile seizure in children
- MMR and MMRV - slightly higher (measles, mumps, rubella and measles, mumps, rubella, and varicella)
- PCV13 vaccination on its own
- When influenza, vaccine was given with the DTap or the PCV13, risk for seizure is greater
- Risk is, at most, 30 seizures in 100,000 - often still given together
- Risk of FS with influenza illness itself is higher than the risk associated with the vaccine
- CDC states the following vaccines lead to a slightly increased risk of febrile seizure in children
- Much is still not known about febrile seizures6
- Rapid change in temperature resulting in “abnormal electrical activity” and its effect on the developing nervous system is essentially the extent
- Long term effects are rarely associated with generalized seizure
- Study: Management of Pediatric Febrile Seizures7
- Cause is unknown, however, it is assumed there is a connection between environmental and genetic factors
- Possible that the release of cytokines during an infection/fever may alter normal brain function and trigger the seizure
- Risk factors for febrile seizure include:
- Male
- Family history
- Elevated body temp
- Underlying cause of the fever
- Prenatal and natal complications
- Low serum calcium
- Sodium or blood sugar
- Microcytic hypochromic anemia
- Iron and zinc deficiencies
- Most common infections associated with FS in children
- Chickenpox
- Influenza
- Middle ear infections
- Upper and lower airway infections
- Tooth infections
- Gastroenteritis
- Signs and symptoms:
- Loss of consciousness
- Difficulty breathing
- Pallor/turning blue
- Foaming at the mouth
- Eyes rolling to the back of the head
- Fixed gaze
- Generalized or focal twitching
- Jerking of the arms and legs
- Postictal period for about 30 min (irritable, confused, drowsy)
- Information to collect:
- Nature and duration of convulsions
- Presence and duration of the post-ictal phase
- Recent infectious diseases or fevers
- Recent antibiotic use
- Immunization and vaccination Hx
- Previous FS or epilepsy diagnosis
- Other neurologic condition or disease
- Antipyretics
- Need for rescue anticonvulsants?
- Assessment
- ABCDE
- CBG
- Vital signs taken following convulsions
- Rapid transport
- Meningitis, encephalitis, and brain infections must be ruled out
- Determination between febrile and afebrile seizure needs to be made ASAP to distinguish possible onset of epilepsy
- Other differential diagnoses
- “Rigors: shaking w/o loc
- Febrile delirium: acute and transient confusion associated with a high fever
- Febrile syncope
- Breath holding attacks: children voluntarily hold their breath and may transiently lose consciousness
- Reflex anoxic seizures: children suddenly become limp because of painful events or shock
- Evolving epilepsy syndrome: fever triggers seizure episodes
- Central nervous system infections: meningitis, encephalitis, and brain accesses”
- Children have subtle symptoms associated with intracranial infections, and therefore those must often be ruled out before it is deemed a febrile seizure, specifically if a fever and specific infection is not readily identifiable
- Management:
- Hydration
- Ibuprofen or acetaminophen
- Reduce discomfort from infection rather than preventing additional seizures (not been shown to be effective)
- IO placement
- Proximal tibia
- 2 cm below patella and medial of the tibial tuberosity
- Distal tibia
- 3 cm proximal to the malleolus
- Feel anteriorly and posteriorly to assure needle needle I placed on the central surface of the tibia
- Distal femur
- 1cm proximal to superior border of patella
- 1-2 cm medial to midline
- Older children - humoral head
- Proximal tibia
- Nervous system is responsible for MANY “fundamental” functions
- Breathing, pulse, BP
- Also allows for higher levels of function
- Thought, memory, understanding
- CNS vs PNS
- PNS is composed of the SNS and ANS
- SNS: somatic nervous system - voluntary control
- ANS: autonomic nervous system - involuntary control
- Purpose of the nervous system is to transmit signals between brain (CNS) and body (PNS) and vice versa
- Brain = controlling organ
- Cerebrum; cerebellum; brainstem
- Cerebrum = grey matter and largest component of the brain
- Right and left hemispheres
- Interprets incoming information, processes, emotions, allows for learning and fine motor control9
- Cerebellum = located just below cerebrum “little brain”
- Muscle movements, posture, balance
- Brainstem = highly protected, central
- Comprised of midbrain, pons, and medulla oblongata
- Connection between rest of brain and spinal cord
- “automatic functions”
- breathing, HR, temp, sleep cycles, digestion, swallowing, etc.
- Spinal cord: extension of brainstem
- Transmit information between brain and the body using electrical impulses
- Right vs. Left brain
- Right side tends to control creativity, spatial awareness, art/musical skills
- Left side controls more “speech, comprehension, arithmetic, and writing”
- Right side tends to control creativity, spatial awareness, art/musical skills
- Seizures8
- Dangers of seizures that persist:
- Depletion of cerebral glucose
- Systemic hypoxia
- Hypercarbia
- Hyperthermia
- Changes in BP
- All may result in serious damage
- Dangers of seizures that persist:
- IO Medication Delivery
- IO needle pierces harder exterior of bone (cortical bone) and enters spongy vascular layer - marrow (cancellous bone)
- Contraindicated in fractured bones, its with bone disease, or skin infection over site
- Often require pressure bag for infusion
- Drains into central circulation - why meds can be delivered this way
- When pt is hemodynamically unstable, and peripheral vasculature is inaccessible due to collapse, IO is a helpful option
- Options for b0th manual and drill insertion
Content Creator: Carli Wymore
CAPCE Course Number: 20-EMTP-F3-6203
Total CE Hours: 1
Level: Advanced
EMT-CE uses the NEMSES guidelines as the foundation for every course outline.