Comprehensive Student Notes: Febrile Seizures (Pediatrics)

History Taking

1. My name is ____, I’m a medical student and my doctor wants me to ask you a few questions about your child, is that all right? 
2. What’s his name? How old is he? Does he go to school?
3. What have you come here for today?
1. My child has convulsions/shaking strangely:
1. When did it start?
2. Is this the first time it happens?
3. How long did it last?
4. How was it like (how did it look like)?
5. Which part of the body was shaking?
6. Did his eyes roll up? Did he drool? Did he urinate or pass stool?
7. Was he sleepy and tired after the episode?
8. How many times did this happen since the first episode?
4. Associated symptoms:
1. Does he have a fever? How much is it? Did you measure it? Does it come and go?
2. Is he tired most of the time? Or crying a lot?
3. Does he have muscle aches?
4. Does he have a runny nose?
5. Does he scratch his ear or bend his head to one side?
6. Does he snore or breathe out loud? Does he have strange sounds on breathing?
7. Does he have a rash?
8. Does he have chest pain?
9. Does he have vomiting?
10. Does he have tummy pain?
11. Does he have diarrhea? When was the last time he passed motion? (Constipation)
12. Does he cry when he urinates? What color is the urine?
13. Does he have joint swelling or pain?
5. PMH: 
1. Has he been sick before?
2. Has he come to the hospital before?
3. Has he had any infections?
4. Does he take any medications?
5. What have you given him for this? Have you gone to a hospital/doctor for this time?
6. Does he have allergies? 
6. PSH: has he done any surgeries? 
7. FH: 
1. Does anyone have epilepsy or seizures?
2. Did anyone have similar problem when they were young?
3. Is anyone sick currently? 
8. Birth:
1. Born by natural delivery or cesarean?
2. How many weeks pregnancy?
3. Any complications during birth?
4. Was the baby crying when he first came out?
5. Did they take him to an incubator? Did he have yellow skin color (jaundice) few days later? Fever?
9. Feeding:
1. How many meals a day does he have? What do they consist of?
2. How long was he breast fed for? Was it exclusive?
3. When did you wean him? What did you start giving him first?
4. When did you stop breastfeeding completely?
10. Vaccination?
11. Growth:
1. How much did he weigh when he was born? Height?
2. How much does he weigh now? How tall is he?
12. Development:
1. Gross motor/fine motor/speech/social
13. Other:
1. a. Has he been with a friend/family member with similar complaint recently?
2. b. Has he fallen on his head?

Physical Examination

• Auscultation (do this at the very beginning before the baby/child starts crying):
• Lungs: breath sounds equal bilaterally? Crepitations? Wheezing? Stridor? Decreased air entry? Prolonged expiratory phase?
• Heart: S1 & S2 audible? Murmur? Grade of murmur? Systolic/diastolic? Ejection/holosystolic? Thrill?
• General: lying in bed comfortably? Conscious? Alert? Drowsy? Irritable? Connected to machines? Abnormal movements? Grunting? Nasal flaring?
• Vitals: RR, HR, temperature, blood pressure, pulse oximetry (oxygen saturation)
• Growth chart: height/length, weight, head circumference
• Hands: splinter hemorrhages, osler nodes, janeway lesions, no peripheral cyanosis, capillary refill
• Head: dysmorphic features? jaundice? Palor? mucus membranes dry? Throat congestion? Enlarged tonsils? Condition of teeth? Ear – tympanic membrane? Lymphadenopathy?
• Respiratory: 
• Inspection: chest shape is normal? Recessions? Skin discoloration - petechiae/purpura? 
• Percussion: dullness? hyperresonance?
• Abdominal: 
• Inspection: Skin turgor? Skin discoloration - petechiae/purpura? Distended abdomen? Inverted/everted umbilicus? Apparent masses?
• Palpation: Any tenderness? Rigidity? Guarding? Masses? 
• Liver: Hepatomegaly?
• Spleen: splenomegaly
• Kidney: Balotable? Pain at renal angle?
• Hernia orifices?
• Genitalia
• Musculoskeletal: swelling of joints? Tenderness of joints?
• Skin: skin mottling?
• CNS:
• Cranial nerves: (I will have a specific post on examining cranial nerves in a child/baby)
• Old enough child:
• Olfactory: what is this smell (lemon)?
• Optic: cover one eye and read a text, then the other eye with Snellen chart, with color blindness by asking to tell if an object is red or green, visual fields, ophthalmoscope
• Oculomotor: pupil reflex
• Oculomotor, abducens, trochlear: hold object in front of eye and move to see eye movements, convergence
• Trigeminal: touch face with cotton for sensation and see if baby reacts
• Facial: ask to smile, lift eyebrows, blow out cheeks and resist my fingers, close eyes and resist opening by my fingers
• Vestibulocochlear: 
• If old enough: distract beside one ear and whisper in other, then ask to repeat word whispered
• If younger: ask mother to distract with toy and you make a noise beside ear (out of sight) to see if they turn
• Call baby’s name and see if he responds if above is not working
• Vagus, glossopharyngeal: ask to open mouth and stick tongue out to check for uvula and ask to say “aah”
• Accessory: ask to shrug shoulders against resistance, ask to turn head to side
• Hypoglossal: stick tongue inside of cheek and push against my finger, open mouth and see tongue in rest for fasciculations.
• Very young child/infant/newborn:
• Oculomotor: pupil reflex
• Optic, oculomotor, abducens, trochlear: hold object in front of eye and move to see eye movements if possible
• Facial: see facial expressions, touch face and see if baby reacts, tactile stimulation of face or foot and see face
• Vestibulocochlear: startle reflex  loud clap beside ear out of sight (<7 months= startle reflex BUT >7 months= distraction test)
• Vagus, glossopharyngeal, hypoglossal: ask mother if he sucks well and see if he cries OR put your gloved hand in baby mouth and feel for sucking ability.
• Tone: move limbs passively. Hyper/hypotonia?
• Power: in older children who are cooperative you can ask them to resist. In younger uncooperative, see their movements. Give them something to hold.
• Reflexes: knee (L3-L4) and brachial reflex (C5-C6)

Differentials

• Febrile seizures secondary to an infection
• Shaking chills
• Metabolic: 
• Hyponatremia/hypernatremia
• Hypoglycemia 
• Drug toxicity: antipsychotics, antidepressants
• Trauma on the head
• Neurological: meningitis, encephalitis, abscess, tumor
• Epilepsy

Investigations

• Blood: CBC, CRP, blood sugar, urea and electrolytes, urinalysis, blood culture and urine culture
• CXR if signs of chest infection
• LP: ONLY AFTER STABILIZING PATIENT. CANNOT DO IF PATIENT IS HAS ALTERED MENTAL STATUS.
• If signs of meningitis or encephalitis 
• If child is <12 months old 
• If treated with antibiotics which mask meningeal signs
• EEG if status epilepticus or focal seizure

Management

• When the patient first presents to the ER, first I would do the ABCs, primary resuscitation and make sure he is stable.
• If patient presents with the seizure, give IV diazepam/lorazepam (better because they act faster than rectal and lorazepam has longer effect). If neonate, give phenobarbitone?
• Cold compresses AKA sponging
• Anti-pyretics (paracetamol)
• Antibiotics for the source of infection if found
• Hydration if needed

Febrile Seizures 

Definition

Seizures happening due to increased body temperature not caused by neurological causes with no history of previous afebrile seizures

Characteristics

• Simple: happen between ages 6 months to 6 years, generalized tonic-clonic convulsions, increased temperature, do not recur within 24 hours, family history, last <15 minutes
• Complex: focal convulsions, recur within 24 hours, last >15 minutes. Higher risk of developing future non-febrile seizures.

Risk factors

• High temperature
• Family history (genetic link)
• Viral infection has higher risk
• Immunization (fever on same day due to vaccine has higher risk)

Prognosis

Very favorable, risk of developing future non-febrile seizures is higher in complex febrile seizures (5-10%) and very low in simple (1-2%).

Status epilepticus

Definition

Unremitting seizure lasting longer than 30 minutes without returning to normal baseline 

Management

• Do the ABCs
• Assess airways and ventilate with oxygen
• Establish IV/IO access
• Assess vitals, oxygenation, blood glucose, signs of meningitis, head trauma.
• Treat hypoglycemia or fever if needed.
• Medications based on guidelines (in order starting with first line): 

1. Administer Lorazepam IV/IO
• If access not achieved in 3 minutes buccal/IM midazolam OR rectal diazepam
2. Administer Lorazepam IV/IO after 5-10minutes 
3. Administer Fosphenytoin IV/IO after 5-10minutes (in neonates, phenobarbital is)
4. Phenobarbital OR valproic acid after 5-15minutes

Reference

1. UpToDate. (2015). Management of convulsive status epilepticus in children.
2. UpToDate. (2015). Treatment and prognosis of febrile seizures
3. UpToDate. (2015). Clinical features and evaluation of febrile seizures
4. Pediatrics Recall 4th Ed. (2010).