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GUIDELINES & PROTOCOLS
ADVISORY COMMITTEE
Febrile Seizures
Effective Date: September 1, 2010

Scope
This guideline covers the investigation and management of febrile seizures in children in the Emergency Department (ED). Febrile seizures have been defined as “an event in infancy or childhood, usually occurring between 6 months and 5 years of age, associated with fever but without evidenceof intracranial infection or defined cause”.1 KEY POINTS: 1. Febrile seizures (simple and complex) are almost always benign and generally are not associated with neurological consequences. 2. The mainstay of investigation and treatment is to rule out bacterial infection. 3. There are limited indications for investigations including blood work, neuroimaging or electroencephalography (EEG). 4. Clearexplanation to and reassurance of caregivers is key in the management of the child.

Diagnosis
Febrile seizures are the most common type of seizure and occur in approximately 3 - 5% of children.2, 3, 4 Seizures may occur prior to the onset of the fever or with only a mild fever, but usually the temperature is greater than 38.50C. There is, however, a correlation between lower temperature and ashorter duration of fever before the initial febrile seizure and an increased risk of recurrence of febrile seizure.5 Classification: A Simple febrile seizure in a child who is otherwise neurologically healthy and without neurological abnormality by examination or by developmental history is defined as: • Fever in a child aged 6 months to 5 years; • Single seizure which is generalizedand lasts less than 15 minutes; • Fever (and seizure) is not caused by meningitis, encephalitis, or other illness affecting the brain. A Complex febrile seizure: • Age, neurological status before the illness, and fever are the same as for simple febrile seizure; • Seizure is either focal or prolonged (i.e. >15 min), or multiple seizures occur in close succession. Furtherinvestigations for complex seizures are indicated in Appendix A

BRITISH COLUMBIA MEDICAL ASSOCIATION

Guidelines & Protocols Advisory Committee

Differential Diagnosis Distinguish a febrile seizure from a seizure due to an acute infection such as bacterial meningitis that requires urgent investigation and treatment. A thorough history and physical exam by an experienced clinician is ideal to ruleout bacterial meningitis, encephalitis, gastroenteritis due to Shigella Sp., ingestions (such as diphenhydramine, tricyclic antidepressants, amphetamines, and cocaine), electrolyte abnormalities, hypoglycemia, and head injury (both accidental and abusive).

Investigations:
Routine blood work is not indicated for simple febrile seizures.7 Laboratory investigations are dictated by the clinicalcondition of the child and by an appropriate clinical policy for children of that age presenting to the emergency department with fever. Urine A urinalysis is recommended for patients with no obvious focus of infection. Lumbar Puncture (LP) An LP is not recommended in children considered to be haemodynamically unstable. Strongly consider LP if the child is less than 12 months and consider LP if thechild is less than 18 months. LP is recommended if: • Child has received antibiotics prior to the seizure as partially treated meningitis could be present in children who were on antibiotics prior to the seizure, and in these cases consider an LP regardless of age. Even if an LP is performed and the results are negative, one may consider treatment of meningitis, as cerebrospinal fluid(CSF) may be normal in the early stages of meningitis.6 • Meningeal signs are present: Meningeal irritation is defined as presence of Brudzinski sign (flexion of the neck causes flexion of the patient’s hips and knees), Kernig sign (pain elicited with 90 degree hip flexion and knee extension), or neck stiffness in children older than 1 year of age. In children 1 year or younger,...