Extern conference

1. Extern conference January 3rd 2008

2. Case • A Thai 2 years 10 months old girl • Chief Complaint • Generalized tonic clonic seizure 15 minutes prior to arrival

3. History of present illness • 2 days ago, She had high grade fever and loss of appetite. Her mother gave her paracetamol and tepid sponge. She vomited food when she ate. • A day before, She had high grade fever as well and passed watery stool once. Her mother took her to a hospital.

4. History of present illness • Doctor at a Hospital nearby her house gave her paracetamol, simethicone, motilium, amoxicillin, pseudoephridine and ORS. • After she came back home she still had high fever and got seizure. • During the seizure, her arms and legs was stretch out and no clonus, eyes was stared up. Duration of Seizure was 2 min. After the seizure she slept for one hour.

5. History of present illness • Her mother brought her to Siriraj Hospital. • At ER, after the seizure she awoke without focal neurological deficit. • The doctor at ER administered aspirin syrup and discharged her from ER. • The same day, 15 min prior to arrival she had recurrent seizure. The pattern of seizure was the same as the first time, however she also had clonic movement of her extremities. • She came back to Siriraj hospital and was admitted.

6. Past medical history • She is a healthy girl. • She had two episode of seizures when she had high grade fever at the age of 1 year old. She did not hospitalization and no anticonvulsant agent was administered.

7. Family History • Her father had an episode of seizure with high grade fever when he was a child. • She had no family history of epilepsy.

8. Others history • Development: normal • Vaccination: Complete according to EPI • Nutrition: • Rice for 2 meals with soy milk 6 boxes/day • Drugs & allergy • Sulfa group hypersensitivity • No drug used continuously

9. Physical Examination • Vital Signs T 38 °c PR 136 /min RR 36 /min BP 119/57 mmHg • BW 18.7 Kg (> P99th) Ht 96 cm (P90th-97th) Weight for height = 133.57 % • General Appearance Alert, active, no sunken eye balls, not pale, no jaundice, no skin lesion, no cyanosis, no clubbing of finger, capillary refill < 2sec • HEENT mild injected pharynx and tonsil, tonsils enlargement 3+, TM not injected

10. Physical Examination • CVS regular pulse, normal S1 S2, no murmur • RS Normal breath sounds, no adventitious sounds • Abdomen Soft, mild distention, not tender No hepatosplenomegaly Active bowel sounds

11. Physical Examination • NS E4V5M6, good consciousness, all CN were intact, fundoscopic examination can’t evaluate (uncooperative) normal muscle tone, motor power grade 5 all extremities, no stiff neck

12. Investigation • Complete blood count: Hb 11.9 g/dl Hct 36.4 % MCV 70.9   fL Wbc 20,420 /mm3N 86.9 % L 5.4 % M 5.3 % Eo 0.4 % Platelet 240,000 /mm3 • Peripheral blood smear: normochromic microcytic RBCs platelet : adequete WBC : neutrophils predominate, no band form, toxic granule 1+

13. Investigation • Urinalysis: pH 5 Sp.gr.1.015 Albumin neg Sugar neg Acetone neg Rbc 0-1 /HPF Wbc 0-1 /HPF bacteria 1+

14. Investigation • Na   134     mmol/L   • K    3.7     mmol/L   • Cl 101     mmol/L   • HCO3   19     mmol/L   • Magnesium     2.2     mg/dl   • Corrected Ca    4.8 mg/dl

15. Discussion

16. Problem List febrile seizure which lasted 15 mins and 4 hrs PTA High grade fever, watery diarrhea, vomiting for 1 day Family Hx of febrile seizure in the young : His father Hx of febrile seizure at 1 year old Mild injected pharynx and tonsils Tonsilar enlargement 3+

17. Differential diagnosis Febrile seizure CNS infection Intracranial hemorrhage Metabolic causes Shigellosis

19. Febrile seizure

20. CNS infection Meningitis Encephalitis Brain abscess

21. Intracranial hemorrhage Subarachnoid hemorrhage Peri/intraventricular hemorrhage Subdural hemorrhage

22. Metabolic Hypoglycemia Electrolyte imbalance Hypocalcemia Hypomagnesemia Hypo/Hypernatremia

23. Shigellosis History of acute gastroenteritis with moderate dehydration Toxin induced seizure

24. Diagnosis • Complex febrile seizure • Acute gastroenteritis with moderate dehydration

25. Febrile seizure Marla J. Friedman et al. : Seizures in Children. Pediatr Clin N Am 2006; 53(257– 277). Michelle D. Blumstein et al. : Childhood Seizures. Emerg Med Clin N Am 2007; 25 (1061–1086).

26. Febrile seizure • Convulsion that occurs in association with a febrile illness in children between 6 months and 5 years of age in the absence of an identifiable cause. • Febrile seizures are the most common type of seizure in young children, with a 2% to 5% incidence of children experiencing at least one seizure before the age of 5 years.

27. Febrile seizure

28. Febrile seizure • The peak age for febrile convulsions is between 18 and 24 months. • The exact pathophysiology is unknown, but it seems that a fever lowers the seizure threshold. • Family history of febrile seizures present in 25% to 40% of children with febrile seizures.

29. When to do a lumbar puncture?

30. Investigation : LP • When to Do a lumbar puncture? • Every child < 1 year of age with a febrile convulsion. • Presence of meningeal signs and symptoms. • In case of doubt, if LP is not performed , the paediatrician is advised to review the case within a few hours. HK J Paediatr (new series) 2002;7:143-151

31. When to do an imaging study?

32. Investigation : Imaging • Not necessary in most cases, but exceptions in a child with • papilledema • cranial nerve palsies (eg. 6thnerve palsy) • other persisting focal neurological signs (eg. hemiparesis) • marked depression in mental status HK J Paediatr (new series) 2002;7:143-151

33. Investigation : EEG • Rarely indicated in the management of a simple febrile convulsion • Complex febrile seizure HK J Paediatr (new series) 2002;7:143-151

34. Investigation : Blood chemistry • Electrolytes and sugar in a child who is drowsy or dehydration • Toxicology screening if suspicious HK J Paediatr (new series) 2002;7:143-151

35. Acute management : general • Same as other type of seizure • Maintain a clear airway (ABC!!!) • Give oxygen if available • Apply suction for nasal or oral secretions if facility available • Place the child in a semi-prone position • Protect the child from injury • Loosen clothing or remove excess clothing • Monitor vital sign HK J Paediatr (new series) 2002;7:143-151

36. Acute management : terminate seizure • Benzodiazepines are the first drug of choice for persistent seizure activity. • Diazepam is the most common drug used • administer rectal diazepam 0.2-0.5 mg/kg/dose • IV dose is 0.3 mg/kg/dose • The same dose can be repeated every 10 to 30 minutes to a total of 3 doses, if necessary • Lorazepam IV form is not available in Thailand HK J Paediatr (new series) 2002;7:143-151

37. Acute management • Observation for several hours after a febrile convulsion • Patients with a simple febrile seizure may be safely discharged to home with parental reassurance and seizure education. • Follow up care

38. Hospital Admission : indication • Complex febrile seizure • Suspicious of possibility of meningitis and encephalitis • Age < 18 months • Anxious parents or inadequate home care HK J Paediatr (new series) 2002;7:143-151

39. Management : fever • Identify cause of fever • Sponging with tepid water • Antipyretics • Paracetamol 10-15 mg/kg/dose orally every 4-6 h • Paracetamol 10-15 mg/kg/dose IM form if oral route cannot be administered HK J Paediatr (new series) 2002;7:143-151

40. Recurrent Febrile ConvulsionsManagement • Intermittent prophylaxis • Continuous prophylaxis HK J Paediatr (new series) 2002;7:143-151

41. Management : intermittent prophylaxis • Antipyretics and tepid sponge. • Diazepam prophylaxis seems to be effective in reducing the recurrence rate. • Suggested doses for prophylaxis • 0.5 mg/kg administered orally, or rectally every 12 hr whenever the rectal temperature is > 38.5 ํC • Maximum of 4 consecutive doses • Side effects of diazepam • ataxia, lethargy and irritability HK J Paediatr (new series) 2002;7:143-151

42. Management : continuous prophylaxis • Long-term Anticonvulsant Prophylaxis • Phenobarbitone or sodium valproate • Currently Not advise due to • No definitive evidence that anticonvulsants can prevent later epilepsy • Side effects of medications • Only use in highly selected case • based on clinical circumstances and the judgement of the benefit and its side effects HK J Paediatr (new series) 2002;7:143-151

43. Prognosis and outcome • Recurrence Risk of Febrile Convulsion • Risk of recurrence is~ 25- 30% • Major predictor for recurrence of febrile convulsion • Early age of onset • Other predictors; • Duration of fever before febrile seizure • Temperature at onset of seizure • Family history of febrile seizure, Prolonged seizure HK J Paediatr (new series) 2002;7:143-151

44. Will the patient have epilepsy in the future?

45. Risk factor for epilepsy • Children with febrile seizure have only a 1% to 2% lifetime risk • Risk factors for epilepsy • Family history of epilepsy • Complex febrile seizure • Underlying neurologic disorder • If two or more of these risk factors present, the future risk of developing epilepsy is 10%. • General population have 0.5% to 1% lifetime risk of developing epilepsy

46. Intellectual Deficit ? • Intellectual outcome is good • Risk of Intellectual Deficit • Pre-existing neurological or developmental abnormality • Those who developed subsequent afebrile convulsions

47. Parental education and reassurence • Reassurance and education is thus very important. • Information to be provided to parents:

48. What should I do if my child has a convulsion in the future? • Stay calm. • Look at your watch or a clock and time the convulsion. • Do not try to restrain your child and do not put anything in their mouth. • Stay with your child and lay them on their side. • Loosen tight clothing from around the neck and move objects away that may cause injury. • Arrange to see your local doctor/general practitioner after the convulsion has stopped. What is febrile convulsion? What should I do when my child develops fever in the future? Recurrence risk/Prognosis

49. Siriraj hospital : Clinical practice guildline Patient with fever and seizure (age 6 month – 5 years) • Tepid sponge • Antipyretics • Treat infection 1.History taking 2.Physical examination Assess cause of fever • Assess risk factor • Age • Neurological PE • Type of seizure • Age<12 month or 12-18 month with evidence of CNS infection • Abnormal neurologicl exm • Complex febrile convulsion • Age > 18 months • Normal neurologicl exm • Simple febrile convulsion If first seizure >>Reassure and follow up If recurrence >> Discuss about oral diazepam prophylaxis Consider LP CT scan or EEG Abnormal investigation Normal investigation Treat accordingly

50. Progression • First day, she had not repeated convulsions but still high grade fever and minimal watery stool. • By physical examination, she had signs of mild dehydration so intravenous antibiotics should be continued and we corrected her dehydration by IVF replacement as maintenance fluid + 3% deficit .