Pediatric Case of the Week #4: Generalized Shaking

34 month old male with generalized shaking

VS: HR 140  RR 30  Temp 38.0  Sat 96% on RA

34-month-old male with no past medical history, developmentally normal,

presents after generalized shaking episode 45 minutes ago. An hour ago, the

patient was noted by his mother to feel warm and was given ibuprofen. Patient’s

mother was rechecking his temperature when he had generalized, rhythmic

shaking with eyes rolling back. The episode lasted for 5 minutes, after which

the patient was sleepy. No incontinence was noted. The patient has had rhinorrhea

for the past 2 days, but no cough, vomiting, or diarrhea and no fever before

today. The patient had a well-child check in his pediatrician’s office today.

Initial presentation: Well appearing 34 mo, crying.

Primary Survey:

Airway: Crying

Breathing: no apparent respiratory distress, no cyanosis

Circulation: normal capillary refill

Where would you focus your secondary survey?

Thoughts?

Actions?

________________________________________________________________________

Febrile seizures are relatively common and occur in 2-5% of the population.  They affect kids between the age of 6 months and 5 years and are associated with a fever of 100.4 F or higher.  They present WITHOUT evidence of intracranial infection, other defined cause, or neurologic condition.  

This is a simple febrile seizure  

                 1. Generalized

2              2. <15 min

                3. once in 24h period

                4. no prior neurologic history

This is NOT a complex febrile seizure

                1. Focal

                2. >15 min

                3. more than once in a 24h period

                4. known neurologic condition (ex cerebral palsy)

Simple febrile seizures are more common (85%), There is a family history in 25-40% of cases. Viral infections are frequently associated.  More recent studies have found a more frequent association with herpesvirus. (Febrile seizures and primary human herpesvirus 6 infection; Pediatr Neurol. 2010 Jan;42(1):28-31)

 A good rule of thumb is to remember that febrile seizure is related to FEVER.  If you perform an age appropriate evaluation of FEVER, you’ll be doing well. You want to manage the seizure (ABC’s, benzos, phenytoin, phenobarbital).  Regarding workup: RESPECT AND REMEMBER: respect the complex presentation and remember the septic workup. 

If you have a simple presentation, get a FSG. (No other labs or imaging are required for a simple presentation unless they are part of the FEBRILE workup.)  (We’ll be reviewing febrile workup in the 3-36 month age soon.)

There is one modification to the workup; ACEP recommends that you “strongly consider” Lumbar Puncture in <18 month old febrile seizure patient with any of the following:

                History of irritability, poor feeding, or lethargy

                Abnormal mental status or appearance

                Abnormal physical findings of meningitis

                Complex seizures

                Slow return from postictal state

                Pretreatment with antibiotics

In the absence of any of these, LP can be deferred.  Great article from Boston Children’s WOOT-WOOT.  (Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009 Jan;123(1):6-12.)

*This is where Warren should ask…”Does this mean that a child who is undergoing treatment for otitis media should get an LP…by me?!?!?”  (And I would humbly respond…”yes, probably, but it depends on the individual context.”)

Finally, as with all pediatric patients you’ll need to take time to inform the family (ie appropriately anxious parents.)   Febrile seizures are generally benign.

Does my child need epilepsy medication? No, antiepileptic medication is not indicated (risk of toxicity outweighs benefit.)

Should I give my child Tylenol or Motrin to prevent this? No, prophylactic antipyretics do not reduce the risk of recurrence.

Will this happen again? Febrile seizure recur 30-50% of the time. Risk factors include <12 mos, lower temps (<40C), shorter duration of fever (<24 hours), and family history of febrile seizures.

Will my child develop epilepsy? Kids that suffer febrile seizure have only slightly increased risk compared to the general population (which is 1%).

Will my child be able to attend Harvard?  There is no evidence that simple febrile seizures produce any long term CNS damage, lead to cognitive decline, or result in learning problems.  (You’re kid may or may not go to Harvard, but the simple seizure won't affect his or her chances.)

(And finally, my favorite) If this happens again should I place a spoon in my child’s mouth to prevent my child from from choking his/her tongue?

Uhhhh No.