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

    Emergency drug and fluid calculator 
    Resuscitation guidelines

    Key Points

    1. Aim to identify underlying pathology (if any) and assess the risk for future seizures.
    2. Seizures lasting more than 5 minutes should be treated.
    3. EEG should not be routinely performed after a first afebrile seizure.

    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 management algorithm

    Note: Account for benzodiazepine doses given on the way to hospital (e.g. by parents or paramedics) when using this algorithm

    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 to or already taking that medication

    Active seizure flowchart

    afebrile seizure 

    Medications used in acute seizures

    Medication  Dose Comments  
    1st line
    Midazolam

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

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

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

    0.5 mg/kg PR (max10mg)

    IV dose preferable

    Do not give IM

     
    2nd line      
    Phenytoin 20mg/kg IV/IO

    Give as loading dose over 20min in monitored patient (max rate 50mg/min)

    Do not give in age <1month

     
    Levetiracetam 40mg/kg IV/IO (max 3g) Infuse over 5mins  
    Phenobarbitone 20 mg/kg IV/IO (Max 1g)

    Give as loading dose over 20 minutes in a monitored patient.

    Stop infusion when seizure ceases

    Commonly used in neonatal seizures

     
    3rd line      
    Propofol   2.5mg/kg IV/IO stat followed by infusion at 1-3mg/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 1mcg/kg/min    
    Ketamine 1-2mg/kg    
    Pyridoxine 100mg 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

    BGL 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 postictal phase and the effect of any medication has passed

    EEG: rarely required in the acute setting

    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, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    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  

                                                                                                               Last updated July, 2019