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
    • Potential risk factors for FS include4:
      • Viral illness
      • Specific vaccinations
      • Genetic predisposition 
      • Children’s developing nervous system under stress of a fever
  • 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
  • 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
  • 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”
  • Seizures8
    • Dangers of seizures that persist:
      • Depletion of cerebral glucose
      • Systemic hypoxia
      • Hypercarbia
      • Hyperthermia
      • Changes in BP
        • All may result in serious damage 
  • 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.