Febrile seizures: Case

This boy is in febrile status epilepticus. He meets the defining criteria for a febrile seizure (age 6 months to 5 years, fever, no central nervous system infection, no prior afebrile seizure), but the convulsion has lasted 35 minutes, which is over the 30 minute boundary for febrile status epilepticus and makes this a neurocritical emergency. The viral exanthem suggests the fever source, and the absence of meningeal signs is reassuring but does not yet exclude meningitis in a child this age. The immediate priority is to terminate the convulsion and to escalate to second-line therapy, because the two buccal midazolam doses in the community have not worked. ^[3]

Clinical findings and acute termination

The pattern is that of febrile status epilepticus in a child with a viral illness. The 35 minute duration, persisting despite two benzodiazepine doses, marks refractory convulsive status epilepticus that demands second-line therapy without delay. I would secure the airway, give oxygen, confirm the normal bedside glucose, obtain intravenous access, and call for senior paediatric and anaesthetic help. Because the seizure has already been refractory to benzodiazepines, I would give a second-line agent immediately, either intravenous levetiracetam at 40 mg per kg to a maximum of 2.5 g or intravenous fosphenytoin at 20 mg PE per kg, in a high-dependency or intensive care setting with preparation for airway support. ^[1]

If the convulsion persisted, I would proceed to a third-line agent (a midazolam infusion or other anaesthetic agent) under anaesthetic and intensive care guidance. Throughout, I would monitor the oxygen saturation, the airway, and the blood pressure, because repeated benzodiazepines and second-line agents can cause respiratory depression and hypotension. The McIntyre trial underpins the use of buccal midazolam in the community, but its failure here is exactly the scenario in which escalation to intravenous second-line therapy is required. ^[2]