Febrile seizures: SAQ

This child has had a complex febrile seizure. He is within the defining age window (6 months to 5 years) and had a convulsion with fever and no evidence of a central nervous system infection, which confirms a febrile seizure, but the seizure lasted over 15 minutes and recurred within 24 hours, which makes it complex rather than simple. The otitis media is the fever source. The two defining features that change the management are the prolonged duration, which warranted active termination, and the recurrence, which raises the recurrence and epilepsy risk and shifts the counselling. ^[1]

Question 1 (10 marks)

Outline your acute management of this child while the second convulsion is ongoing, and justify your investigation plan. ^[1]

My first priority is to terminate the convulsion, because a febrile convulsion ongoing at five minutes is heading toward status and the longer it lasts the less likely it is to self-terminate. I would secure the airway, give oxygen, confirm the bedside glucose is normal (it is), and obtain intravenous access. Because the convulsion is ongoing, I would give intravenous lorazepam at 0.1 mg per kg, maximum 4 mg, repeated once after five minutes if needed. Where intravenous access is difficult, buccal midazolam at 0.5 mg per kg to a maximum of 10 mg is effective and was shown by the McIntyre randomised trial to terminate seizures at least as well as rectal diazepam. ^[3]

If the convulsion persisted despite two benzodiazepine doses, I would treat it as refractory and give a second-line agent, either intravenous levetiracetam at 40 mg per kg (maximum 2.5 g) or intravenous fosphenytoin at 20 mg PE per kg, in a high-dependency or intensive care setting with airway support. I would call for senior paediatric and anaesthetic help early. A febrile convulsion lasting over 30 minutes would be febrile status epilepticus, a neurocritical emergency. ^[1]

My investigation plan is selective. Because this is a complex rather than a simple febrile seizure, I would consider an electroencephalogram and neuroimaging, particularly given the prolonged duration. A lumbar puncture is not routinely required in a fully immunised child over 12 months without meningeal signs, and the 2011 AAP guideline supports observation here, but I would maintain a low threshold if his conscious state deteriorated or meningeal signs emerged. I would identify and treat the fever source (otitis media) and give antipyretics for comfort. ^[1]