Simple Febrile

Seizure
Baguio, Bayana, Lachica, Paasa, Romero
 Outline

1 Case

Some terms & definitions

Terms 2 & importance

Lumbar Puncture
& Neuroimaging
3 Diagnosis

Antipyretics,
Therapy 4 Antiepileptics

Prognosis EEG
Case of
T.S., 1-yr old female, Born
Again, Filipino, born last
October 15, 2021, currently
residing at Bulua, Cagayan
de Oro City.
Chief Complaint

Generalized stiffening
of the extremities
 History of Present Illness

2 days PTA

- onset of cough and

coryza
- mild relief of
symptoms with
medications
- no fever, decrease in
activity, or change in
appetite
 History of Present Illness

2 days PTA 1 day PTA

- onset of cough and - occasional cough

coryza and coryza still
- mild relief of present
symptoms with - onset of fever
medications (38-39.5 C)
- no fever, decrease in - Ibuprofen syrup was
activity, or change in given as needed for
appetite fever
- change in appetite
 History of Present Illness

2 days PTA 1 day PTA 30 minutes PTA

- onset of cough and - occasional cough - patient’s fever

coryza and coryza still persisted
- mild relief of present - 1 episode of
symptoms with - onset of fever generalized
medications (38-39.5 C) stiffening of
- no fever, decrease in - Ibuprofen syrup was extremities, upward
activity, or change in given as needed for rolling of eyeballs,
appetite fever circumoral cyanosis
lasting for 2 ½ mins
Review of Systems
- unremarkable
 Past Personal History
Gestational History
● T.S, was born to a 28-yr old
G2P2 (2002) mother
● Regular prenatal check-up
starting at 3 months AOG
● Took Hemarate, calcium, and
folic acid
● Non -smoker, non-alcoholic
beverage drinker, non-illicit
drug user
Birth History
● T.S. was born term (39 wks),
BW 3100 grams, via NSD at a
lying-in clinic
● Apgar score 9,10
● No complications and
interventions done
 Past Personal History
Neonatal History Feeding History
● No convulsions, hemorrhage, ● Exclusive breastfeeding until
injury, congenital abnormality complementary feeding
● Patient did not have jaundice started at 6 months of age
● Newborn and hearing ● Introduced on regular table
screenings normal food a month ago
● Good appetite
 Past Personal History
Developmental History Past Illnesses
● At par with age ● No prior admission
● No history of measles, chicken
pox, mumps
● No known history of allergy
and food or drug intolerance
Immunization History
- fully immunized at their local health center

Family History
- Patient’s 6-yr old brother had an episode of
generalized tonic and clonic movements of all
extremities with concurrent fever when he was 4
yrs old
- Paternal grandfather has DM
Socioeconomic/Environmental History
- Mother is a housewife and father works as a
company driver
- Patient lives with both his parents and older
brother in a house made of concrete materials
with adequate ventilation
- Father drinks alcohol occasionally but is a
nonsmoker
- Family uses filtered water for drinking and cooking
 Physical Exam
General Survey Vital Signs
Patient was examined awake, ● BP = 90/65 mmHg
alert, non-irritable, febrile, not in ● HR = 112
respiratory distress, and seated ● RR = 27
on the mother’s lap ● T = 37.8 C
● O2 sat = 98%
 Physical Exam
Anthropometrics
● Length = 75 cm ● Length-for-Age = normal
● Weight = 10 kg ● Weight-for-Age = normal
● BMI = 17.8 kg/m2 ● BMI-for-Age = normal
● Weight-for-Length = possible
risk of overweight
Physical Exam
● Skin = good turgor, hot to touch, (-) rashes, (-)
pallor or cyanosis
● HEENT = symmetrical facial features, (-) facies,
closed anterior and posterior fontanels,
non-sunken eyeballs, (+) clear watery nasal
discharge, moist lips and oral mucosa
● C/L = ECE, clear breath sounds, (-) retractions
● CVS = adynamic precordium, distinct heart
sounds, (-) murmur
● Abdomen = globular, soft, NABS
Physical Exam
● GUT = grossly female genitals
● Extremities = full and equal pulses, CRT <2s
● Neurologic
○ Mental Status = awake, alert, non-irritable
○ Cranial Nerves = intact and normal
○ Motor, Sensory, Cerebellar = intact
○ Primitive reflexes absent, Deep tendon
reflexes normal
Primary Working Impression

Simple Febrile Seizure

01
Introduction
Some terms & definitions & importance
Simple Febrile Seizure
● Age: 3 months to 6 years (CPG, 2006)
● Age: 6 months to 6 years (Nelson’s)
● Axillary temperature 37.8 ºC or greater
● Generalized tonic-clonic seizures
● ≤ 15 minutes
● Does not recur within the same febrile illness
● Normal Neurologic Examination
● No underlying CNS infection or abnormality
● Prevalence unknown in Philippines
● Most frequent cause of emergency room consultations and even admissions
 Febrile Seizures
Simple Complex*

Duration Lasts a few seconds to ≤ 15 minutes > 15 minutes

Initially generalized & tonic-clonic,

Presentation then initially a brief period of Focal seizure activity
post-ictal drowsiness

Deficits No focal neurologic deficits May gave focal neurologic deficit

None Repeated convulsions occur

Recurrence
Occurs only once in 24 hours within 24 hours

* Fulfillment of any one of the features of complex febrile seizures classifies it as such
Generalized versus Focal
Treatment algorithm for the
management of febrile seizures.
(Modified from Mikati MA, Rahi A:
Febrile seizures: from molecular
biology to clinical practice,
Neurosciences [Riyadh] 10:14-22,
2004.)
02
Diagnosis
Procedures: Lumbar Puncture & Neuroimaging
Lumbar Puncture
● For CSF analysis
○ Specially if the child is less than 18 months of age.
○ At <18 months child, the typical findings of acute suppurative
meningitis (neck rigidity, Kernig’s, Brudzinski) may not be shown due to
the presence of open anterior fontanelle.
■ Pressure dissipates through the anterior fontanelle
● For more than 18 months, go clinical
○ Meningeal signs
○ If no meningeal signs, you may differ doing the lumbar tap
Signs of Meningeal Irritation
Neuroimaging
● Should not be routinely performed in children for a first simple febrile
seizure
● Absence of evidence
03
Therapy
Antipyretics, Antiepileptics
Antipyretic Drug Use
Antipyretic drugs are used to lower fever and should not be
relied upon to prevent recurrence of febrile seizures.

● Acetaminophen and ibuprofen

○ Effective in reducing fever
○ Little evidence in reducing the incidence of febrile
convulsions
○ Educational interventions aimed at reducing parental fear
and helping them care for their children during febrile
illnesses may be more efficacious.
Antiepileptic Drug Use
Continuous Anticonvulsant (Phenobarbital or Valproic acid)

The use of continuous anticonvulsant is NOT recommended in

children after a first simple febrile seizure. Although anticonvulsants
can reduce the recurrence of febrile seizures, the adverse side
effects of these do not warrant their use in this benign disorder.
Antiepileptic Drug Use
Continuous Anticonvulsant (Phenobarbital or Valproic acid)

● Burden of Illness
○ Important outcomes altered:
■ occurrence of subsequent febrile seizures and/or epilepsy
■ afebrile seizures
○ Recurrence:
■ 1st simple febrile episode < 12 months: 50%
■ 1st simple febrile episode > 12 months: 30%
Antiepileptic Drug Use
Continuous Anticonvulsant (Phenobarbital or Valproic acid)

● Considerations for the draft recommendation for the Philippine

setting:
○ The draft recommendation does NOT recommend the
prophylactic use of continuous anticonvulsant for the prevention
of seizure recurrence because of the side effects of these drugs
and the benign nature of simple febrile seizures.
Antiepileptic Drug Use
Intermittent Anticonvulsant

“The use of intermittent anticonvulsant (whether Phenobarbital or diazepam) is

not recommended for the prevention of recurrent febrile seizures.”

● Knudsen study: no difference in risk of seizure recurrence in children

receiving intermittent diazepam vs placebo

● Considerations for the draft recommendation for the Philippine setting

○ Because there is no difference in the risk of seizure recurrence in
children receiving intermittent diazepam and placebo, the draft
recommendation does not recommended the use of intermittent
anticonvulsants to prevent seizure recurrence
Antiepileptic Drug Use
Intermittent Anticonvulsant

● Nelson: In general, antiepileptic therapy, continuous or intermittent, is

not recommended for children w/ one or more simple febrile seizures

● Parents should be
○ counseled about relative risks of recurrence of febrile seizures and
recurrence of epilepsy
○ educated on hot to handle a seizure acutely
○ given emotional support
04
Prognosis
Electroencephalogram
“EEG should not be routinely requested in children with a first simple
seizures”

● Abnormal EEG after the first unprovoked or afebrile seizure

predicts recurrence for another epileptic attack

● Patients w/ afebrile seizure, w/c show epileptiform activity on EEG,

have a 54% recurrence rate

● In new onset febrile seizures, EEG does not reliably predict who
would have another febrile seizure or who would develop epilepsy
in the future
Electroencephalogram
● Considerations for the draft recommendation for the Philippine setting
○ Because there is no evidence that EEG can predict future incidence of
epilepsy, it is not recommended for prognosticating children w/ simple
febrile seizures
■ Paroxysmal abnormalities in EEG does not change recommendation
that these children w/ febrile seizures should not be treated w/
anticonvulsants

● Nelson: if the child is presenting w/ the first febrile seizure and is otherwise
neurologically healthy, an EEG need not be performed as part of the
evaluation
○ An EEG would not predict the future recurrence of febrile seizures or
epilepsy even if result is abnormal
Summary
Summary
1. Lumbar puncture performed in all children below 18 months for a first simple febrile seizure. For
those children ≥ 18 months of age, lumbar puncture should be performed in the presence of clinical
signs of meningitis (e.g. presence of meningeal signs, sensorial changes).
2. Neuroimaging studies should not be routinely performed in children for a first simple febrile seizure.
3. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of
febrile seizures.
4. The use of continuous anticonvulsants not recommended in children after a first simple febrile
seizure. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse effects
of these do not warrant their use in this benign disorder.
5. The use of intermittent anticonvulsant (whether Phenobarbital or Diazepam) not recommended for
the prevention of recurrent febrile seizures.
6. Electroencephalogram should not be routinely requested in children with a first simple febrile
seizure.
References
● Philippine Pediatric Society (2006). Clinical Practice
Guideline on First Simple Seizure. Retrieved from
https://www.scribd.com/document/414036669/CPG-first-s
imple-febrile-seizure last November 17, 2021.

● Bayana, T.. 2021, April 26. “Seizure in a Child (Drop like a

Puppet)”. Pediatrics Lecture, XUJPRSM.
 Identifying information

Mercury Venus Mars

It’s the closest planet to Venus has a beautiful Despite being red, Mars is
the Sun and the smallest name and is the second actually a cold place. It’s
one in the Solar System planet from the Sun full of iron oxide dust
Hydrocephalus Vs. Normal Brain

Pression

Enlarged ventricle Normal ventricle

 Patient Medical History

Age Gender Allergies Location

19 Female None London, UK

Venus has a Saturn is a gas giant Neptune is far away Mars is actually a
beautiful name with several rings from Earth very cold place

2006 2009 2013 2021

“This is a quote, words full of wisdom
that someone important said and
can make the reader get inspired.”

—Someone Famous
 Review Of Systems
Mercury is the closest planet to the Sun, but does its name
have anything to do with the liquid metal?

Mercury Venus Mars

It’s the closest planet to Venus has a beautiful Despite being red, Mars is
the Sun and the smallest name and is the second actually a cold place. It’s
one in the Solar System planet from the Sun full of iron oxide dust
 Physical Examination
Mercury Mars
It’s the closest Mars is actually a
planet to the Sun very cold place

Venus Neptune
Venus is the second It’s the farthest
planet from the Sun planet from the Sun

Jupiter Saturn
It’s the biggest It’s a gas giant and
planet of them all has several rings
A Picture Is Worth A Thousand Words
 Age Of Diagnosis
Mercury
It’s the closest planet to the Sun

Mars
Mars is a cold place

Venus
Venus has a beautiful name

Earth
Follow the link in the graph to modify its data and then
paste the new one here. For more info, click here It’s the third planet from the Sun
9H 55M 23S
Is Jupiter's rotation period

333,000.000
Earths is the Sun’s mass

386,000 Km
Is the distance between Earth and the Moon

Dr. Daniel
Petterson
“Despite being red, Mars
is a cold place, not hot. It’s
full of iron oxide dust,
which gives the planet its
reddish cast”
Discussion
Dr. William Dr. Samantha
Cameron James
“Jupiter is a gas giant and “Venus has a beautiful
the biggest planet in the name and is the second
Solar System. It's the planet from the Sun. It’s
fourth-brightest object in terribly hot, even hotter
the night sky” than Mercury”
Discussion Jupiter is a gas giant and the biggest planet in the Solar
System. It's the fourth-brightest object in the night sky. It was
Summary named after the Roman god of the skies and lightning
 Comparison
Jupiter Mars Mercury Jupiter

Symptom 1

Symptom 2

Symptom 3

Symptom 4

Symptom 5
 Diagnosis

Mars Jupiter
Despite being red, It’s the biggest planet
Mars is a cold place in the Solar System

Venus Saturn
Venus is the second Saturn is a gas giant
planet from the Sun and has several rings
 Treatment

Venus Mars
Venus is the second planet Despite being red, Mars is a
from the Sun cold place

Earth Saturn
Earth is the third planet from Saturn is a gas giant and has
the Sun several rings
 Patient Monitoring

Week 1 Week 3
Venus is the Venus is the
second planet second planet
from the Sun from the Sun
Week 2 Week 4
Venus is the Venus is the
second planet second planet
from the Sun from the Sun
150,000
Big numbers catch your audience’s attention
 Contraindications & Indications

● You can describe the reason to
stop the treatment here
● You can describe the reason to
stop the treatment here
● You can describe the reason to
stop the treatment here
● You can describe the reason to
stop the treatment here
● You can describe the reason to
start the treatment here
● You can describe the reason to
start the treatment here
● You can describe the reason to
start the treatment here
● You can describe the reason to
start the treatment here
 Post-prevention

Venus Mercury
Venus has a beautiful name and Mercury is the closest planet to
is the second planet from the the Sun and the smallest one in
Sun. It’s hot there the Solar System

Earth Saturn
Earth is the third planet from the It's a gas giant and has several
Sun and the only one that rings. It's composed mostly of
harbors life in the Solar System hydrogen and helium
 Case Timeline

It’s the closest

planet to the Sun
1 Mercury

It's the biggest

Jupiter 2 planet of them all

It’s the farthest

planet from the Sun
3 Neptune

It's the second

Venus 4 planet from the Sun
Awesome
Words
Map
Mercury
It’s the closest planet
to the Sun

Venus
Venus is the second
planet from the Sun

Saturn
Saturn is a gas giant
and has several rings
Conclusions
Mercury is the closest planet to the
Sun and the smallest one in the Solar
System. This planet's name has
nothing to do with the liquid metal,
since Mercury was named after the
Roman messenger god

● Mars
● Venus
● Saturn
References
● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

● AUTHOR (YEAR). Title of the publication. Publisher

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