Clinical Practice Guidelines

Afebrile seizures


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    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Background to condition

    Most convulsions are brief and self limiting, generally ceasing within 5 - 10 minutes. These seizures do not need immediate management unless they continue beyond this timeframe.

    Seizures should be treated immediately in the following situations:

    - Child presents actively fitting (cause and duration unknown)
    - Known cause warranting more urgent treatment

    • Meningitis
    • Hypoxic injury
    • Trauma
    • Underlying cardio-respiratory compromise

    Assessment

    Assessment and management need to occur concurrently if the child is actively convulsing.

    Key considerations in assessment include:

    •  Any compromise to ABC?
    • Duration of seizure including pre-hospital period?
    • Significant past history including seizures, neurological comorbidity including VP shunts, renal failure (hypertensive encephalopathy), endocrinopathies (electrolyte disturbance)?
    • Focal features?
    • Fever? (Febrile convulsion or CNS infection)
    • Anticonvulsant medications including any acute pre hospital treatment?
    • Previously successful acute anticonvulsant management?
    • Evidence of underlying cause that may require additional specific emergency management?
      • Hypoglycemia
      • Electrolyte disturbance including hypocalcemia
      • Meningitis
      • Drug overdose
      • Trauma (consider occult head trauma)
      • Stroke and intracranial haemorrhage

    Note

    It is now recognised that some children can have a presentation with convulsions and an acute infectious illness (particularly gastroenteritis) without documented fever. This is sometimes referred to as " afebrile febrile convulsions". The management and prognosis is the same as for classical  febrile convulsions.

    Acute management

    In most situations (see above) supportive care for 5 - 10 minutes is appropriate.  Ensure adequate airway and breathing while waiting for convulsion to stop spontaneously.

    If seizure persists or the onset has not been witnessed, pursue active management (see management algorithm and drug dose table). Include benzodiazepines given on the way to hospital (eg by parents or paramedics) when using this algorithm.

    • Support airway and breathing, apply oxygen by mask, monitor.
    • Secure IV access, check bedside BSL and send urgent specimen for calcium / electrolytes and venous blood gas. If hypoglycaemia present, also see  Hypoglycaemia guideline and correct the low sugar. Give benzodiazepine.
    • Repeat benzodiazepine after 5 minutes of continuing seizures.
    • If convulsion continues for a further 5 - 10 minutes, commence IV phenytoin or phenobarbitone. If IV access cannot be secured and seizures refractory to benzodiazepines, consider IO access.
    • Consider pyridoxine (100mg IV) in young infants with seizures refractory to standard anticonvulsants.
    • Seek senior assistance if seizure not controlled.  Anticipate need to support respiration.  Thiopentone or Propofol and rapid sequence induction (RSI) may be required for seizure control.
    • Also see Active seizure management flowchart

    Table of Medications see  drug doses:

     Drug  Route  Dose Comments
    Midazolam  IV /IO/IM
    Buccal
    Intranasal 
    0.15 mg/kg
    0.3 mg/kg (max 10mg)  
    0.2-0.5 mg/kg (max 10mg)
    IV route preferable but alternate routes can be used if rapid IV access not achieved.
    If 2 appropriate doses fail to terminate the seizure, further doses are unlikely to be effective and increase the risk of respiratory depression.
    Use plastic ampoules for buccal and intranasal dosing.
    Diazepam IV/IO
    PR
     

    0.1-0.3 mg/kg

    0.3-0.5 mg/kg (max 10mg)

     IV route preferable but alternate routes can be used if rapid IV access not achieved.
    If 2 appropriate doses fail to terminate the seizure, further doses are unlikely to be effective and increase the risk of respiratory depression.Use the rectal kits for PR dosing.

    Phenytoin
    Phenobarbitone
    IV/IO
    IV/IO
    20 mg/kg
    20 mg/kg
    Both given as loading doses over 20 minutes in a monitored patient.
    Midazolam Infusion IV/IO Titrate dose

    1 - 5 micrograms/kg/min
    Incremental increase until control. Only to be initiated in a high dependency setting with involvement of senior staff.  May be considered for treatment of refractory seizures as an alternative to RSI and ventilation.
    Propofol  IV/IO  2.5mg/kg stat followed by infusion at 1-3mg/kg/hr  for no longer than 48 hours  Use only with involvement of senior staff confident with airway management. For refractory seizures requiring RSI and ventilation. Beware hypotension.
    Thiopentone(may not be available at all hospitals)

    IV/IO  2-5 mg/kg slowly stat followed by IV infusion at 1-4 mg/kg/hr  Use only with involvement of senior staff confident with airway management. For refractory seizures requiring RSI and ventilation. Beware hypotension.

    Ensure all children have their BSL checked and corrected.   See  hypoglycaemia guideline.

    Consider checking electrolytes if this has not been done previously. In particular, consider hypocalcaemia in dark-skinned children.

    Consider consultation with local paediatric team

    • Infants
    • Prolonged seizures
    • Incomplete recovery
    • Focal seizures or post ictal findings
    • Previous seizures
    • Developmental delay
    • Existing comorbidities

    When to consider transfer to tertiary centre

    - Child requiring care beyond the comfort level of the hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Follow up

    All other children with a first afebrile seizure who have fully recovered should be referred to the local paediatric team for follow up.

    Parent information sheet

    Information Specific for RCH

    Children with afebrile seizures are normally admitted under general paediatrics, unless known to another team.

     Other Epilepsy Resources

    This includes links to many drugs, the use of rectal and oral diazepam, and buccal midazolam.

    Last updated September 2011