Pediatric emergency medicine trisk 1446 1446
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patient is at first presentation, the greater the likelihood of recurrence. In addition,
recurrences are more likely to recur in patients with lower temperatures on
presentation of their first seizure (lower than 40°C) and shorter duration of fever
before the seizure (less than 24 hours) and in patients with a family history of
febrile seizures. Most recurrences (75%) will happen within 1 year. The exact risk
of developing epilepsy after a febrile seizure is unknown, but most studies
indicate that it is less than 5%. Risk factors for developing epilepsy after a febrile
seizure include abnormal development before the episode, a family history of
afebrile seizures, and a complex first febrile seizure; without any of these risk
factors, the risk of developing epilepsy is approximately 1%, which is almost the
same risk as in the general population.
The treatment of a patient who presents with a febrile seizure is nearly identical
to that for other seizure types. The primary goal is the establishment of a clear
airway; secondary efforts are then directed at the termination of the seizure and
concurrent lowering of body temperature. However, because most febrile seizures
are brief in duration, the typical patient who presents for the evaluation of a
febrile seizure is no longer seizing upon arrival to the ED. In those instances, if
the history is consistent with a simple febrile seizure, the patient has no stigmata
of a CNS infection, and the patient’s neurologic examination is completely
normal (other than the patient may be postictal or slightly hyperreflexive), further
evaluation for the cause of the seizure is unnecessary. As such, routine laboratory
studies are not recommended for the patient with a simple febrile seizure. While
seizure may be the first manifestation of meningitis, LP is only indicated for
children in whom meningitis is clinically suspected and it is no longer
recommended routinely. Similarly, routine neuroimaging or EEG screening is not
recommended for the patient with a first-time simple febrile seizure. However,
the evaluation should focus on the possible cause of the fever. Outpatient EEG is
performed in some institutions for patients with complex febrile seizure. While
complex febrile seizures are associated with a slightly higher risk of subsequent
epilepsy, the predictive value of these EEG studies and their yield on
management changes remains controversial.
A patient who has had a febrile seizure and is well appearing and back to
baseline may be safely discharged to home. Parents should be reassured that
febrile seizures are common and that most patients have no further episodes.
They need to be cautioned that a recurrence may happen and should be given
simple instructions on what to do should another seizure occur and indications for
returning for evaluation. They can also be instructed on the proper use of
antipyretics, even though studies have failed to demonstrate that this is effective
