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Afebrile seizures

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  • See also

    Emergency drug and fluid calculator 
    Resuscitation

    Key Points

    1. Aim to identify reversible cause and manage accordingly.
    2. Seizures lasting more than 5 minutes should be treated.
    3. EEG should not be routinely performed after a first afebrile seizure.
    4. Ensure parental education regarding safety and future seizures.

    Background

    Unprovoked seizures are common in children with around 8% having a seizure by 15 years of age. Most seizures are brief and self-limiting, generally ceasing within 5 minutes.

    Seizures should be treated immediately in the following situations (see flowchart below):

    • child actively seizing with duration unknown, or seizure for >5 minutes
    •  known pathology
      • meningitis
      • hypoxic injury
      • trauma
    • cardio-respiratory compromise

    Assessment

    Assessment and management should occur concurrently if the child is actively seizing. 

    Key considerations in acute assessment

    • Duration of seizure including pre-hospital period
    • Past history: previous seizures and anti-seizure medication (management plan if in place), neurological comorbidity (e.g. VP shunt, structural brain abnormality) renal failure (hypertensive encephalopathy), endocrinopathy (electrolyte disturbance)
    • Focal features
    • Evidence of underlying cause that may require additional specific emergency management. Underlying causes include:
      • hypoglycaemia
      • electrolyte disturbances
      • meningitis
      • drug/toxin overdose
      • trauma
      • stroke and intracranial haemorrhage
    • Age: treatable cause is more likely in children <6 months

    History

    Detailed chronological history of events and behaviours before, during and after the seizure

    History should be taken from the child if possible and obtain bystander account

    Ask about:

    • aura, focal features
    • level of awareness
    • recent trauma, consider non-accidental injury
    • focality of limb or eye movement
    • post-ictal phase/hemiparesis

    Relevant past history

    • Family history of seizures or cardiac disorders/sudden death
    • History suggestive of absence seizures or myoclonic jerks, nocturnal events
    • Developmental history  

    Examination

    • Full neurological examination looking for any abnormal neurological findings, signs of meningitis or raised intracranial pressure
    • Cardiovascular examination including BP and look for any signs that suggest an underlying cause e.g. neurocutaneous stigmata, microcephaly

    Red Flags

    • Head injury with delayed seizure
    • Developmental delay or regression
    • Headache prior to the seizure
    • Bleeding disorder, anticoagulation therapy
    • Drug/alcohol use
    • Focal signs

    Differential diagnosis of seizure

    • Arrhythmia
    • Breath holding spell (episode occurs when the child is crying)
    • Vasovagal syncope with anoxic seizure (postural change, preceded by dizziness and nausea)
    • Non-epileptic paroxysmal disorder

    Management

    Initial support

    In most situations, observation for 5 minutes is appropriate whilst waiting for seizure to stop spontaneously

    Treat the child the way the parents will at home – keep safe and observe

    At this stage there is no need to check oximetry or apply oxygen

    Active seizure flowchart

    • Account for benzodiazepine doses given pre-hospital (e.g. by parents or paramedics)
    • If available, refer to patient specific seizure management plan in children with a known seizure disorder
    • Do not give a medication if the child is allergic, has previously been unresponsive, or if he/she already taking it

    Active seizure flowchart

    afebrile seizure 

    Medications used in acute seizures

    Medication  Dose Comments
    1st line
    Midazolam

    0.1 mg/kg IV/IM (max 10 mg)

    0.3 mg/kg buccal/IN (max 10 mg)

    Diazepam 0.3 mg/kg IV/IO (max 10 mg)

    0.5 mg/kg PR (max 10 mg)

    IV dose preferable

    Do not give IM

    2nd line      
    Phenytoin

    Loading dose:

    20 mg/kg IV/IO

    Infuse undiluted into a large vein over 20 min (max rate 50 mg/min) in a monitored patient 

    Do not give in age <1 month

    Levetiracetam 40 mg/kg IV/IO (max 3g) Dilute to 50 mg/mL and infuse over 5 mins 
    Phenobarbitone 20 mg/kg IV/IO (Max 1g)

    Dilute to 20 mg/mL or weaker and infuse over 20 mins (max rate 30 mg/min) in a monitored patient.

    Stop infusion when seizure ceases

    Commonly used in neonatal seizures

    3rd line      
    Propofol   2.5 mg/kg IV/IO stat followed by infusion at 1-3 mg/kg/hr  


    For refractory seizures requiring rapid sequence induction and ventilation. Use only with involvement of senior staff confident with airway management. Beware hypotension.

    Thiopentone 2-5 mg/kg IV/IO slowly stat followed by infusion at 1-4 mg/kg/hr 
    Midazolam infusion 1 mcg/kg/min  
    Ketamine 1-2 mg/kg  
    Pyridoxine 100 mg IV Consider in children up to 6 months with seizures refractory to standard anticonvulsants

    Post seizure care

    Position child in recovery position, maintain airway 
    Monitor for further seizure activity 
    Consider investigations as appropriate

    Investigations

    Bloods

    Blood glucose should be performed as soon as possible

    Consider electrolytes, calcium and venous gas in the following circumstances:

    • any seizure needing a second line agent
    • children <6 months
    • medical comorbidity such as metabolic disorder, diabetes, dehydration
    • child has not returned to baseline once the post-ictal phase and the effect of any medication has passed

    Imaging

    Consider in the following circumstances:

    • focal seizure
    • patients requiring 3rd line agent
    • children <6 months
    • signs of elevated ICP
    • bleeding disorder/anticoagulation
    • child has not returned to baseline once the post-ictal phase and the effect of any medication has passed

    EEG

    • rarely required in the acute setting
    • not indicated as a routine test following all first seizures
    • benign focal epilepsy of childhood (BFEC) (also known as benign childhood epilepsy with centrotemporal spikes or benign rolandic epilepsy) and idiopathic generalised epilepsy (IGE) are the most common causes of afebrile seizures in children.   Diagnosis of either cannot be confirmed without EEG.  BFEC and IGE may not require treatment, so EEG confirmation is usually not urgent.  An EEG should generally be performed if a child has a second seizure.  A positive diagnosis can avoid the need for neuroimaging


    Consider consultation with local paediatric team when

    • Children <6 months
    • Prolonged seizures
    • Incomplete recovery
    • Focal seizures or post-ictal findings
    • Recurrent seizures without a diagnosis of epilepsy
    • Frequent/uncontrolled seizures in a child with known epilepsy
    • Developmental delay
    • Existing comorbidities

    Consider admission for observation in children <6 months  

    Consider transfer to tertiary centre when

    Children anticipated to require ICU level care (cardiorespiratory compromise).

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services.

    Consider discharge when

    In older children, when the child is back to baseline function with no red flags on history, examination or presumed cause

    All families should receive education prior to discharge which includes:

    • explanation of risk of recurrence
    • seizure first aid and management plan
    • advise parents to video events if safe to do so and keep a record
    • provide written information
    • consider need for emergency medication (buccal midazolam)

    Follow-up after a first afebrile seizure

    • All children who have a first afebrile seizure should have medical follow up
    • EEG should not be routinely performed after a first afebrile seizure

    Parent information sheet 

    Kids Health Info (Vic)

    Seizures – safety issues and how to help 
    Epilepsy 
    Midazolam for seizures 
    Electroencephalography

    PENNSW First seizure pack and video


                                                                                                               Last updated August 2020

  • Reference List

    1. AMH Children’s dosing companion. Retrieved from https://childrens.amh.net.au/ (viewed August 2019).
    2. Dalziel S et al. Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial. The Lancet. 2019. 393 (10186), p2135-2145.
    3. Lyttle M et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. The Lancet. 2019. 393 (10186), p2125-2134.
    4. NICE guideline Epilepsies: diagnosis and management. Retrieved from https://www.nice.org.uk/guidance/cg137/chapter/1-Guidance (viewed August 2019).
    5. PENNSW Retrieved from http://pennsw.com.au/index.php/clinicians (viewed August 2019)
    6. The Royal Children’s Hospital Melbourne Paediatric injectibles guideline. Retrieved from https://pig.rch.org.au/monographs/ (viewed August 2019).