Learning Outcome

1. List the causes of febrile seizure
2. Describe the types of febrile seizures
3. Summarize the treatment of febrile seizures
4. Recall the nursing management of a patient with a febrile seizure

Introduction

Febrile seizures are generalized seizures, typically in children between the ages of 6 months and 5 years, that occur with a fever >100.4 °F (38 °C) not associated with a central nervous system (CNS) infection, a known seizure-provoking etiology (eg, electrolyte imbalance, hypoglycemia, or substance abuse), or history of an afebrile seizure. Febrile seizures are categorized as simple febrile seizures, consisting of a single seizure, only <15 min long, or complex febrile seizures, characterized by multiple seizures occurring within 24 hours, focal neurologic features, or a seizure lasting ≥15 min.[1] Simple febrile seizures comprise the majority of febrile seizures.[2][3]

Nursing Diagnosis

• Fever
• Headache
• Altered mental status
• Unresponsive
• Confused

Causes

Febrile seizures occur with a fever >100.4 °F (38 °C) not associated with a central nervous system (CNS) infection, a known seizure-provoking etiology (eg, electrolyte imbalance, hypoglycemia, or substance abuse), or a history of an afebrile seizure. The highest fever necessary to cause febrile seizures is specific to the individual, as each child's threshold convulsive temperature varies. While the degree of the fever is ultimately the most significant factor in febrile seizures, these seizures often occur as the patient's temperature rises. A febrile seizure may be the first sign that a child is ill, with a fever >100.4 °F (38 °C) discovered shortly after that. No fever etiology is more likely than others to cause febrile seizures. Any fever may cause a febrile seizure.[3][4]

Risk Factors

The exact age constituting a febrile seizure varies slightly throughout medical literature, with ages 6 months to 5 years being a common working range. Febrile seizures are prevalent, occurring in up to 4% of children in this age group. Some children have a single febrile seizure event, and others have multiple events over early childhood.

Assessment

A detailed description of the seizure event is essential for evaluating a possible febrile seizure patient. Historical information regarding the exact appearance and length of the event is vital. Information regarding the symptoms of a central nervous system (CNS) infection, underlying structural abnormalities, personal history of neurologic problems, personal immunization history, and personal or family history of prior seizure is essential in deciding whether an event of concern constitutes a febrile seizure or rather constitutes a more severe illness presenting with a seizure.

Once a seizure is qualified as a febrile seizure, the examiner should seek additional information to differentiate whether it is simple or complex. Simple febrile seizures occur more commonly than complex febrile seizures and are characterized by a seizure that is generalized, lasts less than 15 minutes, and does not recur within 24 hours. Complex febrile seizures have at least one of the following: focal features, >15 minutes duration, and recurrence within 24 hours. In either instance, a general physical and neurologic exam is necessary. Postictal drowsiness is not abnormal in febrile seizures but typically resolves within a few minutes. A patient recovering from a febrile seizure will rapidly return to baseline neurologic exam. If a patient does not return to baseline, remains entirely unresponsive to noxious stimuli after the seizure, or has other symptoms of acute neurologic dysfunction before the seizure (such as acute headaches, alteration of mental status, or concern for weakness), other complicating etiologies should be a consideration.

Evaluation

Patients who have a presentation and clinical features consistent with simple febrile seizures do not need further diagnostic studies due to the benign nature of this type of febrile seizure. However, if a patient's history is consistent with a complex febrile seizure, a thorough evaluation is recommended, which usually involves ruling out any structural or infectious causes and obtaining an electroencephalogram (EEG). Laboratory studies (eg, complete blood count, complete metabolic profile, and urinalysis) should also be performed if a patient has signs of dehydration, poor fluid intake, vomiting, or diarrhea.[5] Some cases of complex febrile seizures may require hospital admission for observation and further studies.[4][6]

A lumbar puncture is not necessary for a patient with simple febrile seizures and a rapid return to baseline; however, the study is recommended when there are signs or concerns of a CNS infection. A lumbar puncture should also be considered in infants presenting after a febrile seizure who are aged <12 months, not adequately immunized against Streptococcus pneumoniae or Haemophilus influenza type B, had seizure 2 days after fever onset, or taking antibiotics which may mask meningitis or other CNS infection.[7]

Medical Management

No specific treatment for simple or complex febrile seizures is indicated other than supportive care and evaluation for possible underlying conditions causing the fever. Antipyretics have not been shown to prevent a recurrence of febrile seizures. In those who have recurrent febrile seizures, prevention is challenging. A few studies have examined the treatment with benzodiazepines as a bridging measure for a few days during subsequent febrile events; however, the adverse effects outweighed the potential benefits. Therefore, benzodiazepines are not a recommended preventative measure.[8][9][10] 

Nursing Management

• Assess mental status.
• Obtain vitals.
• Look for an infectious cause (eg, otitis media or urinary tract infection).
• Measure the fluid ins and outs.
• Monitor hydration status.
• Administer acetaminophen or a benzodiazepine as prescribed.
• Monitor temperature.
• Ensure patient safety during a seizure.
• Recommend hydration.

When To Seek Help

• Loss of consciousness (LOC)
• Status epilepticus
• Unresponsive

Outcome Identification

• Alert and stable
• No seizure activity

Monitoring

• Assess mental status.
• Obtain vitals.
• Look for an infectious cause (eg, otitis media or urinary tract infection).
• Measure the fluid ins and outs.
• Monitor hydration status.
• Administer acetaminophen or a benzodiazepine as prescribed.
• Monitor temperature.
• Educate the caregiver about febrile seizures.

Coordination of Care

Febrile seizures are not uncommon in the pediatric population. They only occur when there is a rise in body temperature. These seizures are benign and generally have no long-term complications in most children. Diagnosing and managing these children should be done in a systemic fashion in collaboration with other specialists like the pediatrician and neurologist. The nurse should educate the family that even though dramatic in appearance, these seizures do not lead to neurological disease or dysfunction. The more parents know about this disorder, the less likely they will rush to the emergency room. However, the parents should also be educated on when to bring the child with a seizure to the ER because, in some cases, the cause may be a virus or a bacterial infection of the brain. The pharmacist should educate the family on managing the fever with acetaminophen, not aspirin. However, the family should also be educated that antipyretics do not prevent febrile seizures.[11][12] 

Outcomes

The prognosis for most children with a febrile seizure is excellent. About 30% of children who have one febrile seizure will experience another seizure later on. The risk of epilepsy in the future is slightly increased compared to the general population. However, a simple febrile seizure does not affect cognition intellect or induce neurological dysfunction.[13][14]

Health Teaching and Health Promotion

The key is patient education. The nurse practitioner should educate the family that even though dramatic in appearance, these seizures do not lead to neurological disease or dysfunction. The more parents are aware of this disorder, the less likely it is that they will rush to the emergency room or seek alternative, unproven remedies. However, the parents should also be educated on when to bring the child with a seizure to the emergency department because, in some cases, the cause may be a virus or a bacterial infection of the brain. The pharmacist should educate the family on managing the fever with acetaminophen, not aspirin. However, the family should also be educated that antipyretics do not prevent future febrile seizures.[11][12] 

Discharge Planning

Febrile seizures are not uncommon in the pediatric population. They only occur when there is a rise in body temperature. These seizures are benign and generally have no long-term complications in most children. Diagnosing and managing these children should be done in a systemic fashion in collaboration with an interprofessional team that consists of the pediatrician and neurologist.

The key is patient education. The nurse practitioner should educate the family that even though dramatic in appearance, these seizures do not lead to neurological disease or dysfunction. The more parents are aware of this disorder, the less likely it is that they will rush to the emergency room or seek alternative, unproven remedies. However, the parents should also be educated on when to bring the child with a seizure to the emergency department because, in some cases, the cause may be a virus or a bacterial infection of the brain. The pharmacist should educate the family on managing the fever with acetaminophen, not aspirin. However, the family should also be educated that antipyretics do not prevent future febrile seizures.[11][12] Finally, patients need to be told that a febrile seizure does not lead to any adverse neurological or psychological problems.

Evidence-Based Issues

The prognosis for most children with a febrile seizure is excellent. About 30% of children who have one febrile seizure will experience another seizure later on. The risk of epilepsy in the future is slightly increased compared to the general population. However, a simple febrile seizure does not affect cognition intellect or induce neurological dysfunction.[13][14]

Pearls and Other issues

Most patients with a febrile seizure event do not require hospitalization or intensive medical interventions. Occasionally, a patient with a prolonged complex febrile seizure of a focal nature may develop focal weakness, commonly known as Todd's paralysis. Typically, this resolves within a few hours, but it may take up to a few days for complete resolution. Even though febrile seizures are often considered relatively benign, studies have shown that patients with a febrile seizure status have an increased risk of developing mesial temporal sclerosis, which can increase future chances of focal epilepsy. Febrile seizure status is defined as a seizure lasting >30 minutes. Therefore, prompt treatment of prolonged seizures of a febrile nature is as necessary as for protracted seizures arising from other etiologies.

As mentioned above, it is vital to quickly expand the differential diagnosis considerations if a patient is not awakening and steadily improving toward baseline or has unexpected abnormalities on the neurologic exam. A patient who will not respond to noxious stimuli after a seizure or who appears to be waxing and waning in mental status needs evaluation for possible ongoing seizure activity. The standard procedure for this evaluation is typically a prolonged EEG study. Other considerations in a patient not recovering as expected include intracranial abnormalities such as a tumor, hemorrhage, hydrocephalus, stroke, or another significant metabolic abnormality.