Febrile Seizures

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OBJECTIVES

• Discuss frequency of febrile seizures
• Review assessment of the febrile seizure patient
• Outline prehospital care of the febrile seizure patient

      While responding to a call for an infant who was "blue and not breathing," I began to think of all the causes of respiratory arrest, which was the likely problem, and what assessments would confirm those causes.

   The first things that came to mind were:

• Foreign body airway obstruction
• Toxin exposure
• Emesis with aspiration
• Seizure
• SIDS.

   Walking through the door expecting the worst, I was quickly reassured by the cooing 8-month-old being held by his mom. "He was blue, twitching all over and not breathing when I found him," she said. "Now he is fine."

   As my partner and I began our assessment, we learned that the boy had been sick for several days with a productive cough and a possible ear infection. Our problem list was quickly narrowing toward a febrile (fever-caused) seizure.

PEDIATRIC SEIZURES

   There are many causes of seizure in pediatric patients. Although fever is the most common, other causes include:

• Hypoxia
• Brain injury
• Hypoglycemia
• Septic infection
• Intoxication
• Congenital neurological problems
• Hypovolemia.

   A febrile seizure happens when a child age 5 months to 5 years has a temperature greater than 102°F.¹ There may be generalized or focal seizure activity.

   Febrile seizures are classified as simple or complex. Features of a simple febrile seizure are:^2-4

• Tonic-clonic movement
• Stops without intervention
• Less than 15 minutes' duration
• Does not recur within 24 hours
• No previous neurological problems.

   Complex febrile seizure characteristics include:^2-4

• Longer than 15 minutes' duration
• Includes focal features
• Recurs within 24 hours
• Known patient history of neurological problems.

   Complex febrile seizures are more worrisome, have increased likelihood of significant consequences, and are more likely to need ALS interventions and transport. In this article, we explore febrile seizure assessment, treatment and transport considerations.

FREQUENCY OF FEBRILE SEIZURES

   Febrile seizures are a relatively common occurrence in children ages 5 months to 5 years and are most frequently caused by viral illness.⁴ Thirty percent of seizures in this age group are caused by fever; the next highest cause is failure to take prescribed medications. Febrile seizures may occur in as many as 5% of all children. There may be a genetic connection for febrile seizures, but the exact pathway is not well understood.^4,5

   About 30% of children who have a febrile seizure are likely to have more in the future. Factors associated with having an additional febrile seizure include:¹

• Younger than 15 months at time of first seizure
• Experiences frequent fevers
• Family (parent and/or sibling) history of seizures
• Seizure occurs soon after fever began
• Seizure happened at a relatively low body temperature.

FEBRILE SEIZURE SIGNIFICANCE

   In most cases, febrile seizures have no lasting impact on the child. Basic life support skills may be needed to clear the child's airway or treat wounds from a fall or injury that occurs during the seizure, but most children who have a febrile seizure develop normally with no lasting consequence.¹

   A small percentage of children--2% to 5%--who have a febrile seizure will develop epilepsy. The risk increases if the febrile seizure was complex, meaning it was prolonged, had focal features, recurred within 24 hours of the first seizure, and/or the child has underlying medical problems like cerebral palsy or other types of physical or cognitive developmental delays.¹

   Witnessing a febrile seizure can cause a parent or caregiver considerable distress. Calming and reassuring witnesses after the seizure has occurred may be your most important and necessary treatment action.

   Even though febrile seizures are frequently described as "harmless," it is important to remember that a serious illness like influenza, sepsis or meningitis may have caused the child's fever.⁶ These illnesses can cause other significant complications such as hypovolemia, respiratory distress and metabolic abnormalities. Use the patient assessment to look for signs and symptoms of the problem that caused the fever.

   During a seizure there is a dramatic increase in cellular demand and use of energy. To meet those needs, cells rapidly metabolize glucose to produce adenosine triphosphate (ATP). Because of the high degree of brain activity and metabolization, oxygen demand also increases. Cerebral blood flow to the brain is increased during a seizure to provide the increased amounts of oxygen and glucose, but also to remove carbon dioxide that is being produced.

   The cerebral blood flow can respond to the metabolic demands created by a seizure as long as hypoxemia, hypoglycemia and cardiac irregularities do not develop. Hypoglycemia and hypoxia can result from increased metabolic activity in contracting skeletal muscles, particularly if the patient experiences multiple seizures. In that situation, the brain may require more energy than the body can produce. Cellular exhaustion and some cellular destruction are the usual serious consequences.

   A generalized seizure results from abnormal and excessive activity throughout the brain, which leads to tonic-clonic activity throughout the body. A focal seizure only affects one part of the brain, thus the symptoms depend on the area of the brain that is impacted.

ASSESSMENT

   When assessing the patient, focus on determining if the problem is emergent, the stage of the seizure, potential causes and pertinent medical history. Begin the assessment as you enter the room, using the Pediatric Assessment Triangle (PAT) to decide "emergency" or "no emergency." The components of the PAT are work of breathing, skin condition and general appearance. The decision of emergency or no emergency will guide your next assessment steps and the need for rapid ABC interventions.

   Determine if the seizure is still in progress by gauging the child's level of consciousness. If the seizure is still in progress, is it focal or generalized? If the seizure is over, is the child postictal?

   When assessing level of consciousness, compare against age-appropriate norms. Also ask parents or caregivers about the child's level of consciousness and its comparison to normal. Examine how the child is interacting with his environment, known caregivers and new people, like EMS professionals. A child who is listless, uninterested or oblivious to changes in his environment may still be seizing, be postictal and/or have a significant underlying illness or injury.

   Signs and symptoms associated with a fever include warm, red or flushed skin, diaphoresis and chills. Potential associated symptoms include generalized pain, specific pain complaints, lethargy, malaise, rash and mental status changes.

   If you did not witness the seizure, ask bystanders about it. How long was it? Ask for a description of the seizure to try to determine if it was focal or generalized. For example, was only part of the body shaking or was the entire body shaking? Were there multiple seizures? Has the child had seizures before?

   During the history-taking portion of the assessment determine the child's neurological health and developmental status. Children who have a febrile seizure often don't have a neurological illness and are developing normally.⁵ Be sure to ask if the child has any known neurological disorders. Also ask about sibling and parent history of febrile seizures and neurological disorders.

   Vital sign assessment includes heart rate, respiratory rate, skin condition, blood pressure, capillary refill and pulse oximetry. Assessment should also include blood glucose determination with a glucometer, as hypoglycemia may be present. If the child is warm, the parent reports a fever, and/or you suspect fever as the seizure cause, measure the child's temperature, if you are trained and authorized to do so. For infants and toddlers to age 3, rectal temperature is the most accurate core temperature measurement. An oral thermometer is appropriate for older children.

   While it is commonly believed that a rapid rise in core temperature is the cause of febrile seizures, this theory is not supported by research.⁴ Also, EMS responders are not likely to know the rate of temperature change, and, as such, it is not useful for making treatment decisions.

   Vital signs are most useful when trended over time. Reassess vital signs every 5 to 15 minutes, depending on the child's condition and application of interventions. It is important to know or have access to age-based norms in a field guide, protocol book or smartphone application.

   Ask the parents or caregivers about their interventions before your arrival. Specifically, did they administer any antipyretic (fever-reducing) medications like acetaminophen or ibuprofen, two commonly administered over-the-counter antipyretic medications? Ask the name of medications given, dose amount and time last administered. Also determine if any other medications have been given for an acute illness or for chronic medical problems.

FEVER CAUSE

   During assessment, use the SAMPLE history, vital sign trends and the physical exam to try to determine the cause of the child's fever. Many routine childhood illnesses like sinus infection, ear infection, and upper or lower respiratory infection can cause fever. During your assessment, ask the patient and/or their parent about recent illness and complaints of ear or head pain, nasal congestion, cough, wheezing or upper airway swelling. Ask about recent urination--amount, frequency, discoloration and abnormal smell. A urinary tract infection can include fever.

   Serious illnesses like meningitis and encephalitis can cause fever and seizures. Check for symptoms like headache, neck stiffness, deteriorating mental status and reduced level of consciousness.

   While a seizure is a neurological problem, make sure you assess the child for problems that may have either led to the fever or been caused by the seizure. When assessing the respiratory system, look and listen for lower airway congestion and constriction, as well as upper airway swelling.

   The child may have a neurological problem, such as epilepsy, that caused the seizure. Inquire about the child's medical history and medications. Failure to take prescribed medications is a frequent cause of pediatric seizures.

   Sepsis, a systemic and life-threatening infection, can lead to relative hypovolemia and vasodilation. Look for signs and symptoms of shock during the assessment, like dry mucous membranes, pale and clammy skin, tachycardia, tachypnea and abnormal mental status.

   Finally, an ill child with a fever who has a seizure may have had a febrile seizure. During the assessment, always be a detective and look for other causes like hypoxia, hypoglycemia, brain injury or intoxication. As you gather assessment information, you may be able to eliminate some causes from consideration.

TREATMENT

   Febrile seizures are often over before EMS arrives. Treatment will depend on the patient assessment findings. If the patient is still seizing, focus on ABC support, which may include airway positioning, suctioning secretions, blood or vomit, and applying high-flow oxygen. Oxygen administration is critical because tonic-clonic activity uses a large amount of oxygen. Children have a smaller oxygen reserve than adults and can become profoundly hypoxic from even a short seizure. If the seizure does not resolve quickly, consider using airway adjuncts and other airway management tools.

   If the child is still seizing, assure that dangerous objects have been moved aside, nothing has been inserted into the child's mouth and the child is not being restrained. Begin passive cooling techniques for a febrile patient during the assessment to increase heat dissipation and patient comfort.⁷ Some simple passive cooling methods include removal of extra layers of clothing and application of cool, not cold, compresses to the forehead, head and/or chest. Discontinue the cool compress if it is causing the child additional distress. Do not immerse or submerge the child in a cold bath, and do not place ice packs directly on the child's skin. Consider fanning as a cooling method or moving the patient into a cooler environment. Do not induce shivering when using any passive cooling techniques.

   ALS providers should follow local protocols for choosing and securing a route of administration for a benzodiazepine like midazolam or diazepam if the seizure is still in progress. Potential administration routes include intravenous, intramuscular, intraosseous, intranasal and rectal. If the child's current weight is unknown, use a length-based pediatric dosing tape to estimate the child's weight and calculate a dose. Follow local protocols for additional doses if the seizure persists or another seizure occurs.

   If the child is postictal, the focus of care is supportive. Provide treatment based on assessment findings. Assure an open airway and reposition as needed. Inspect the oropharynx for any signs of soft tissue trauma and wounds, as well as emesis. Suction as needed to remove any blood, emesis or secretions that the child is not able to clear on his own. Administer oxygen as appropriate.

   Use assessment findings to determine the need for obtaining IV access for possible medication and fluid administration. If the child has had multiple febrile seizures and/or has a history of seizures, IV access is appropriate. IV access may not be needed for a child who has had a single simple febrile seizure and is acting normally or has an improving mental status.

   Have a high index of suspicion for hypovolemia in a sick child. Hypovolemia compromises thermoregulatory systems. If signs and symptoms of hypovolemic shock are present, following local protocols, administer a weight-based fluid bolus that may range from 10-20 mL/kg.

   Parents may wish to administer an oral antipyretic medication like acetaminophen or a nonsteroidal anti-inflammatory drug (NSAID) like ibuprofen. If the child is not in full control of his own airway, nothing should be administered by mouth. If parents seek your approval to administer antipyretic medication before they refuse or accept transport, consult your local protocols and/or contact online medical control.

   Infants and toddlers have immature thermoregulatory systems. Acetaminophen directly impacts the hypothalamus and increases heat loss through peripheral vasodilation and sweating.⁸ Ibuprofen has a different effect by interfering with metabolic processes that affect heat production and loss.⁸

   The ability of paramedics, with protocol authorization, to administer an anti-pyretic medication varies considerably in EMS systems. In the U.S., several paramedic protocols include oral administration of acetaminophen or ibuprofen for children who have not had a recent parent-administered dose and have an adequate level of consciousness.^9,10 Paramedics in the United Kingdom are allowed to administer the analgesic and antipyretic paracetamol (acetaminophen) as an oral suspension. Indications include absence of seizure activity, fever, and previous history of a febrile seizure.¹¹

   A 2009 Archives of Pediatrics & Adolescent Medicine reported that administration of an antipyretic may not prevent the recurrence of a febrile seizure. One of the study's concluding comments was, "Parents should be informed about the inefficacy of antipyretic agents during a febrile episode that leads to a febrile seizure and about the benign nature of febrile seizures themselves."¹²

   Seizures have many causes. If the seizure resulted from hypoglycemia, follow your local protocols for oral or IV dextrose administration. Hypoxia from causes like narcotic-induced respiratory depression or foreign body airway obstruction could also cause the seizure. Oxygen and/or naloxone may be indicated, depending on your assessment findings.

   Finally, anticipating and preparing for additional seizures is an important treatment step. Use ongoing monitoring to look for signs of another generalized or focal seizure. If the parents are refusing transport, be sure to inform them of seizure signs, the importance of calling 9-1-1 if another seizure occurs, and the importance of follow-up with their child's primary care provider.

PARENT/CAREGIVER REASSURANCE AND EDUCATION

   Although febrile seizures are usually short and an isolated event in an otherwise healthy child, they can cause considerable stress for parents. Involve parents and caregivers in the assessment to learn important details from their observation of the seizure, the child's history of recent illness and lifetime medical history.

   A simple febrile seizure in a developmentally normal and neurologically healthy child is not indicative of future neurological delays or disease.^4,5 Febrile seizures are almost always isolated and, while frightening, are relatively harmless to the child.

   Use the incident as an opportunity to discuss parental recognition and treatment of illness, the importance of learning infant and child BLS skills, and practicing general infection control. In our experience, many parents regret summoning help when their child is back to normal by the time the ambulance arrives. Reassure the parents that they did the right thing by calling 9-1-1 when they observed the seizure.

TRANSPORT CONSIDERATIONS

   Fever may or may not be the cause of a seizure, even though fever is the largest reason for pediatric seizures. Given the wide range of possible causes, transporting the child to a hospital for additional evaluation is usually indicated. Inform parents and caregivers of the importance of monitoring and rapid intervention if the child has another seizure. Nonemergent transport in an ambulance can be provided for a postictal child or one who has returned to his normal/baseline mental status.

   A 2009 study published in Pediatric Emergency Care examined the need to transport febrile seizure patients by ALS instead of BLS ambulance.¹³ The authors concluded, based on their analysis, that "simple febrile seizure patients are suitable for transport via BLS." They added that additional studies should be done to confirm their conclusion. Actively seizing children from any cause or children who have had a complex febrile seizure should receive ALS transport.

   When transporting any pediatric patient, remember these important principles:

• Secure the child in a size-appropriate infant/child passenger seat that is secured to the cot or captain's chair.
• Do not allow a parent to hold the child during transport.
• Position the child for continuing monitoring and treatment as needed.
• Transport other, non-ill children in a privately owned vehicle whenever possible.

   If the child has a history of neurological disorders, has significant underlying infection or other indications based on your local protocols, consider transportation to a pediatric specialty hospital, if available.

TOP TIPS: ASSESSING RECTAL TEMPERATURE

   Follow these tips to assess rectal temperature in an infant or toddler under age 3.

1. Use a specific rectal probe with the thermometer.
2. Lubricate the insertion tip of the probe cover with a water-based or petroleum lubricant for patient comfort.
3. Position the infant supine, remove diaper and bring the infant's knees to the chest to clearly visualize the anus.
4. Insert the probe about half an inch into the anus. Stop if you meet resistance.
5. Once the probe is inserted, use your other hand to stabilize the probe, if needed, and to keep the child's legs positioned near his chest. As needed, ask a parent or partner for assistance to maintain infant positioning.
6. Maintain the probe position until the thermometer indicates temperature assessed.
7. Remove and clean probe; clean infant's bottom with a wipe or tissue.

   For male infants, cover the penis with a towel or diaper to prevent uniform contamination during the procedure.

ADDITIONAL RESOURCES

   Learn more about common pediatric medical emergencies, pediatric assessment and pediatric traumatic injury in NAEMT's Emergency Pediatric Care (EPC). EPC is available in a unique hybrid format that combines online training with classroom skills instruction. See www.naemt.org/education/epc_a.aspx.

CONCLUSION

Although stressful to observers, simple pediatric febrile seizures are rarely life- threatening and are not associated with long-term neurological complications. EMS professionals need to be able to distinguish simple febrile seizures from complex seizures. Since the seizure is rarely witnessed by EMS, a thorough interview with bystanders is necessary to determine the seizure type. Treat febrile seizures by reducing core temperature, administration of antipyretics, if trained and authorized, and benzodiazepines only if the child is still seizing. Monitor and be prepared for additional seizures. If the parent refuses transport, evaluation by the child's primary care provider should be strongly encouraged.

References

1. National Institutes of Neurological Disorders and Stroke. Febrile Seizures Fact Sheet. www.ninds.nih.gov/disorders/febrile_seizures/detail_febrile_seizures.htm.

2. Callegaro S, Titomanlio L, Donega S, et al. Implementation of a febrile seizure guideline in two pediatric emergency departments. Pediatr Neurol 40:78-83, 2009.

3. Millar J. Evaluation and treatment of the child with febrile seizure. Am Fam Phys 73(10):1762-1764, May 2006.

4. Tejani NR. Pediatrics. Febrile seizures. https://emedicine.medscape.com/article/801500-overview.

5. Baumann R. Febrile seizures. https://emedicine.medscape.com/article/1176205-overview.

6. National Institutes of Neurological Disorders and Stroke. NINDS Febrile Seizures Information Page. www.ninds.nih.gov/disorders/febrile_seizures/febrile_seizures.htm.

7. W. Chapleau, A. Burba, P. Pons, D. Page, eds. The Paramedic, pp. 1083-1084. New York: McGraw-Hill, 2009.

8. Graento J. Pediatrics, Fever. https://emedicine.medscape.com/article/801598-overview.

9. South Plains Emergency Medical Services Pre-Hospital Treatment Protocols for EMT Paramedic. https://www.b-rac.org/Files/2010-2011%20Protocols/ParamedicProtocols10-11.pdf.

10. North Central Connecticut EMS Council Regional EMS Guidelines. https://www.northcentralctems.org/documents/June%202%202009%20NCCEMS%20EMS%20Guidelines%20g.pdf.

11. Pre-Hospital Emergency Care Council. Appendix 1-Medication Formulary. https://www.phecit.ie/Documents/Clinical%20Practice%20Guidelines/EMT%203rd%20Edition%20CPGs/EMT%20Appendix%201%20Medication%20Formulary.pdf.

12. Strengell et. al. Antipyretic Agents for Preventing Recurrences of Febrile Seizures. https://archpedi.ama-assn.org/cgi/content/abstract/163/9/799.

13. Brodsky R, Merlin M, Leva E, et al. Do all pediatric patients who have a febrile seizure require transport by advanced life support? Ped Emerg Care 25(5):317-320, May 2009.

   Greg Friese, MS, NREMT-P, is an e-learning designer, podcaster, author, presenter and paramedic, as well as a lead instructor for Wilderness Medical Associates. Read more from him at the EverydayEMSTips.com blog. Connect with Greg at EMSUnited.com, Facebook.com/gfriese or twitter.com/gfriese.

   Kevin T. Collopy, BA, CCEMT-P, NREMT-P, WEMT, is an educator, e-learning content developer and author of numerous articles and textbook chapters. He is also a flight paramedic for Spirit Ministry Medical Transportation in central Wisconsin and a lead instructor for Wilderness Medical Associates. Contact him at kcollopy@colgatealumni.org.