First seizure and seizure mimics — branching viva

Branching viva across three children brought after a possible first seizure: a febrile toddler whose seizure has stopped, testing the febrile-versus-meningitis decision; a school-age child with a clear first unprovoked seizure, testing classification and the recurrence-risk conversation; and an adolescent still convulsing at fifteen minutes, testing the status epilepticus ladder from benzodiazepine to second-line agent.

branching clinical structured oral2 min readVerification in progress

Prompt

You are the paediatric registrar covering the emergency department and the ward. The examiner asks you to assess three children in sequence: an eighteen-month-old who has had a brief generalised convulsion with a fever; a nine-year-old who had a first generalised tonic-clonic seizure at home and is now back to normal; and a fourteen-year-old who is still convulsing on arrival at fifteen minutes. The examiner releases information in stages and will press you on your thresholds and your doses.

Stem 1 — Eighteen-month-old with a febrile convulsion (5 minutes)

An eighteen-month-old boy is brought to the emergency department after a three-minute generalised tonic-clonic seizure at home. He has now stopped convulsing, is alert and smiling, and has a temperature of 39.2 degrees Celsius with an upper respiratory tract infection. He is previously well and developmentally normal. [8]

Branch A (examiner): Classify this febrile seizure and state which investigations, if any, are required for a child who has recovered like this. [8]

Branch B (examiner): The examiner now tells you the seizure lasted twenty minutes, was focal in the right arm, and the child is still drowsy. How does each feature change your classification and your management, and what is your next investigation? [12]

Branch C (examiner): The examiner asks you to counsel the parents on the risk of recurrence of febrile seizures and the risk of later epilepsy, and to give first-aid advice for the next febrile illness. [8]

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References12Show ledger

[1]Fisher RS; Cross JH; French JA; et al Operational classification of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology Epilepsia, 2017.PMID 28276060
[2]Fisher RS; Acevedo C; Arzimanoglou A; et al ILAE official report: a practical clinical definition of epilepsy Epilepsia, 2014.PMID 24730690
[3]Trinka E; Cock H; Hesdorffer D; et al A definition and classification of status epilepticus--Report of the ILAE Task Force on Classification of Status Epilepticus Epilepsia, 2015.PMID 26336950
[4]Hirtz D; Ashwal S; Berg A; et al Practice parameter: evaluating a first nonfebrile seizure in children: report of the quality standards subcommittee of the American Academy of Neurology, The Child Neurology Society, and The American Epilepsy Society Neurology, 2000.PMID 10980722
[5]Hirtz D; Berg A; Bettis D; et al Practice parameter: treatment of the child with a first unprovoked seizure: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society Neurology, 2003.PMID 12552027
[6]Baldin E; Hauser WA; Buchhalter JR; et al Yield of epileptiform electroencephalogram abnormalities in incident unprovoked seizures: a population-based study Epilepsia, 2014.PMID 25041095
[7]Haut SR; Shinnar S Considerations in the treatment of a first unprovoked seizure Semin Neurol, 2008.PMID 18777475
[8]Subcommittee on Febrile Seizures Neurodiagnostic evaluation of the child with a simple febrile seizure Pediatrics, 2011.PMID 21285335
[9]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
[10]Doss J Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
[11]Dalziel SR; Borland ML; Furyk J; et al Levetiracetam versus phenytoin for second-line treatment of convulsive status epilepticus in children (ConSEPT): an open-label, multicentre, randomised controlled trial Lancet, 2019.PMID 31005386
[12]Berg AT; Shinnar S Complex febrile seizures Epilepsia, 1996.PMID 8635422