Pediatric Emergencies
Seizures during fever are among the scariest experiences for parents, but for clinicians, they’re often benign and self-limited — unless they cross into status epilepticus, where every second counts. Let’s explore both carefully.
🌡️ Febrile Seizures
Definition
A febrile seizure is a seizure associated with fever ≥38°C, occurring in a neurologically healthy child aged 6 months–5 years, without evidence of CNS infection, metabolic abnormality, or prior afebrile seizures. These account for about 2–5% of all children — peaking around 18 months.
Classification
| Type | Duration | Focality | Recurrence within 24 h | Postictal deficit |
|---|---|---|---|---|
| Simple | < 15 min | Generalized | No | None |
| Complex | ≥ 15 min | Focal or multifocal | Yes | May have Todd’s paresis |
💡 Think: Simple = Short, Single, Symmetrical
Pathophysiology
- Immature brain: lower seizure threshold.
- Rapid rise in body temperature triggers abnormal neuronal firing.
- Genetic predisposition: first-degree relatives often have similar histories.
- Cytokine surge (IL-1β, IL-6, TNF-α) during fever can alter neuronal excitability.
Risk Factors
- Family history of febrile seizures or epilepsy
- High fever (>39°C) or rapid temperature spike
- Viral infections (HHV-6, influenza, adenovirus)
- Post-immunization fever (MMR, DTP)
- Iron deficiency anemia
Clinical Presentation
- Often occurs early in a febrile illness.
- Sudden loss of consciousness → generalized tonic-clonic movements.
- Eyes roll upward, limbs stiffen, may froth at the mouth.
- Duration: usually <5 min.
- Followed by brief postictal sleepiness or confusion, but rapid recovery.
🧾 Evaluation
Assessment Steps
- History & Observation: onset, duration, type of movements, fever history, recurrence.
- Physical exam: look for meningitis signs, trauma, or metabolic causes.
- Investigations: Not required for a classic simple febrile seizure. Do basic work-up if: Child < 6 months or > 5 years; Complex features; Signs of CNS infection; Signs of recovery poor or developmental delay. Tests may include CBC, electrolytes, glucose, lumbar puncture, neuroimaging (if focal).
💊 Management
Immediate (During the Seizure)
- Ensure safety: clear surrounding objects.
- Position: place child on their side, head slightly down (recovery position).
- Airway: maintain patency, suction secretions if needed.
- Do NOT: insert objects into mouth or restrain.
- Time the seizure.
If seizure lasts > 5 min:
- IV diazepam 0.3 mg/kg (max 10 mg)
- OR Rectal diazepam 0.5 mg/kg
- OR Buccal/nasal midazolam 0.2 mg/kg
Post-Seizure Care
- Control fever: paracetamol 15 mg/kg + tepid sponging.
- Identify and treat infection (malaria, otitis, pneumonia).
- Observe until full recovery.
- Reassure parents — the episode looks frightening but is usually harmless.
🧩 Parent Counseling
Guidance for Families
- Simple febrile seizures do not cause brain damage or developmental delay.
- Recurrence risk: 30–40% (especially if <18 months, family history, or low fever threshold).
- Epilepsy risk: 2–4% (slightly higher than general population).
- Teach parents: How to position the child safely; When to seek help (seizure >5 min, focal, recurrent); Use of rectal diazepam for home rescue if prescribed.
💥 Status Epilepticus (SE)
When Seizures Don't Stop
Continuous seizure activity for ≥ 5 minutes, or ≥ 2 seizures without full recovery in between. After 30 minutes, neuronal injury begins — hence early termination saves neurons.
Causes
- Poorly controlled epilepsy
- Febrile or CNS infections (meningitis, encephalitis)
- Hypoxia, hypoglycemia, electrolyte imbalance
- Head trauma
- Toxin ingestion or medication non-compliance
🚑 Management: Stepwise Approach
| Step | Action | Drug & Dose | Key Notes |
|---|---|---|---|
| 1. Stabilize (0–5 min) | Airway, Breathing, Circulation | O₂, suction, check glucose | Correct hypoglycemia with 10% dextrose (2 mL/kg) |
| 2. First-line (5–10 min) | Benzodiazepine | Diazepam 0.3 mg/kg IV or 0.5 mg/kg rectal / Midazolam 0.2 mg/kg buccal | May repeat once after 5 min |
| 3. Second-line (10–20 min) | Anticonvulsant | Phenobarbital 20 mg/kg IV (5 mg/kg/min) OR Phenytoin 20 mg/kg IV (1 mg/kg/min) | Monitor ECG, BP, respiratory rate |
| 4. Refractory (20–30 min) | Continuous infusion | Midazolam infusion 0.1 mg/kg/h OR Thiopental infusion | Requires ICU, possible intubation |
🔹 Always correct hypoxia, hypoglycemia, and electrolyte abnormalities first. 🔹 Continuous monitoring — oxygen saturation, BP, temperature, and urine output.
🧩 Complications
- Hypoxic brain injury
- Rhabdomyolysis → renal failure
- Hyperthermia
- Aspiration pneumonia
- Death (if not managed promptly)
🧠 Comparison Snapshot
| Feature | Febrile Seizure | Status Epilepticus |
|---|---|---|
| Trigger | Fever | Various (fever, epilepsy, infection, metabolic) |
| Duration | < 15 min (simple) | > 5 min continuous |
| Consciousness | Regains quickly | Persistent loss |
| Treatment | Usually supportive | Emergency drugs, ICU if needed |
| Outcome | Benign | Life-threatening |
💭 Key Takeaways
- Simple febrile seizures are benign and self-limiting — reassure parents.
- Complex or recurrent seizures warrant investigation.
- Status epilepticus = Neurological emergency. Time is brain.
- Early airway support, prompt benzodiazepine use, and escalation save lives.