THE DIAGNOSTIC AND MANAGEMENT

OF
FEBRILE SEIZURE

I Gusti Ngurah Suwarba

Neuropaediatric Division
Paediatry Department
Medical Faculty - Udayana University
Sanglah General Hospital,
Denpasar

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 Bangkitan
Spell

Kejang

DEFINITION OF SEIZURE
Epilepsi

Sindroma Epilepsi

Fokal/Umum/Klasifikasi (-)

Kejang Demam

Menyerupai kejang/NES

Seizure is a clinical manifestation due to the

releasing of excessive electric load from deteriorated
neurone cells in the brain.
The disturbance can be caused by physiological,
anatomical, biochemical disorder or the combination
of these anomalies.

Seizure : is a medical emergency that have

to be handled quickly and appropriately.
SI-310508
PATHOPHYSIOLOGY OF
SEIZURE

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 +++++++ Na + +++++++

DEMAM
Anatomis,
K+
fisiologi,
biokimia

BANGKITAN KEJANG
 Motor unit a motor neuron and all the
muscle fibers it innervates

Copyright 2005 Pearson

Education, Inc., publishing as
Benjamin Cummings
Seizure process in the brain
Focal seizure
Focal become generalized
Generalized

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 Febrile seizure
Definition
The onset of seizure that occur due to the increasing
of body temperature(rectal temperature) above 38C
which is caused by extracranial process.
(UKK consensus, 2006)

Note
Commonly between 6 month old - 5 year old
Not included:
Electrolyte disturbance
Below 1 month old (Neonatal seizure)
History of seizure not due to fever
(ILAE,1993)
Think of Central Nervous System Infection or
Epilepsy if it happens out of that age range. 7
Factor of fever:

Therate of increasing in body temperature

plays a vital role in causing febrile seizure.
(J.C. Millicap 1968)

Feverwhich has vital role in febrile seizure

Respiratory tract infection >>>
Gastrointestinal tract infection
Urogenital tract infection
Post immunization (beware,
Communication, Information, Education)
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 Febrile seizure classification
Classification
Simple febrile seizure
Complex febrile seizure
Febrile seizure plus (FS+)

(ILAE,1993)

Simple febrile seizure

Last for 15 minutes,
Generalized seizure
Not recurrent within 24 hours
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(ILAE,1993;Stafstrom,2002, consensus 2006)
 .classification continue

Complex febrile seizure

Seizure lasts > 15 minutes

Focal seizure or partial become generalized

Recurrent in 24 hours (multiple)

(Camfield dan Camfield,1995; Shinnar,1999)
(Nelson dan Ellenberg,1978; Berg dan Shinnar. 1996)
(Anneger dkk, 1996)

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 Febrile seizure plus (FS+)
Fixed FS until > 6 year old
FS associated with seizure without fever or epilepsy
Frequent seizure, 13 times per year
Phenotype: Febrile seizure
Genotype : mutation in sodium channel and GABA
FS+ disappear at 12 year old
When undergo EEG, the result is same with normal febrile
seizure, nothing specific can be found
One of the spectrum from GEFS+ epilepsy syndrome
Scheffer IE. Brain 1997;124:479-90
Baulac S. Lancet Neurol. 2004;3

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 Epidemiology

Age :
2%-4 % 6 month-5 year old child, Peak incidence : 18
months
Male > Female
80% Simple febrile seizure
20% Complex febrile seizure
2-7 % child develop become epilepsy

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 Diagnosis
Anamnesis :
Confirm : Seizure or non seizure
Type, duration and frequency of seizure
Find the cause of fever
Find the risk factor
Physical examination:
Evaluate post ictal consciousness is very
important
Neurological examination is in normal range
= tods paresis when long duration seizure
Find the extracranial infection sign 13
 Supporting examination
Laboratory : Not routine, on indication
Complete blood count, electrolyte, blood
sugar
(Level II-2, recommendation D)
(Gerber dan Berliner, 1981; AAP, 1996)

Lumbar puncture(to eliminate probability of

intracranial processmeningitis)
Age < 12 month old strongly recommended
Age 12 18 month old recommended
Age > 18 month old selective
(Level III, recommendation E) 14

(AAP, 1996)
 ..suporting examination

Electroencephalography(EEG): not routine

Unable to predict the recurrence of seizure
and probability of becoming epilepsy
(Level II-2, recommendation E)
(Millichap,1991; AAP,1996)

Agreement neuro-paediatric 2008

EEG still can be done on non specific febrile
seizure : focal febrile seizure, recurrent complex
febrile seizure, febrile seizure plus

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 Management

1. During seizure

2. Post seizure medication

3. Long term prophylaxis

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 ALGORYTHM OF HANDLING ACUTE SEIZURE AND STATUS CONVULSIVE
Diazepam 5-
Prehospital 10mg/rect max 2x 0-10min
5 Minute gap

Hospital/ED Diazepam 0,25-0,5mg/kg/iv/io Monitoring

Airway 10-20min
(rate 2mg/min, max dose 20mg) Vital sign
Breathing
Circulation or EKG
Midazolam 0,2mg/kg/iv bolus Blood sugar
or Serum Electrolyte
NOTE : IF DIAZ RECTAL 1X PRE
HOSPITAL CAN RECTAL 1X Lorazepam 0,05-0,1mg/kg/iv (Na, K, Ca, Mg, Cl)
(rate <2mg/min) Blood Gas Analysis
Anomaly correction
Phenytoin Pulse oxymetry
20mg/kg/iv
ICU/ED 20-30min drug blood level
Note : Aditional (20min /50ml NS)
5-10mg/kg/iv Max 1000mg

Phenobarbitone 30-60min
20mg/kg/iv
Note : (rate >5-10min; max 1g)
Jika preparat (+)
ICU Refracter

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Midazolam 0,2mg/kg/iv bolus Pentotal - Tiopental Propofol 3-5mg/kg/infusion
Continue infuse 2 4 mg/kg/iv
 Post Seizure Medication
Fever therapy, find and solve the etiology of
fever
Antipyretic: Strongly recommended although its
not proven can reduce the risk of
(Level I, recommendation E)
= Acetaminophen 10 15 mg/kg, 3- 4 times/day
= Ibuprofen 5-10 mg/Kg, 3-4 times/day
Prescribe antibiotic when theres indication
Prevent the recurrence of seizure : Very
Important! 18
 Long Term Prophylaxis

I. Intermmitent Prophylaxis

II. Continuous prophylaxis

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 I. Intermmitent Prophylaxis

Diazepam oral 0,3 0,5 mg/kg every 8 hours when

fever, decrease the risk of recurrent seizure
(Level I, recommendation E)
(Knudsen, 1991; Rosman n friends, 1993)

Phenobarbital, carbamazepine, phenytoin cannot

prevent seizure when fever
(Knudsen, 2002)

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 II. Continuous Prophylaxis
Recommended:
Obvious neurological abnormality before or after
seizure (paresis Tods, CP, hidrocephalus, etc)
Long duration seizure> 15 minute
Focal seizure

Consider:
Recurrent multiple seizure within 24 hour
Infant < 12 month old
Recurrent complex febrile seizure > 4 times/year

Duration of treatment : 1 year free of seizure

(agreement pediatric neurology 2008)
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 . Prophylaxis
Anticonvulsant being used:
Phenobarbital 3-5 mg/kg/day
divided into 2 dose
Valproic acid 15-40 mg/kg/day,
dividing into 2-3 dose

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 Prognosis
There are 2 risks :

1. Recurrent febrile seizure

(50-75% normally at first year)

2. Epilepsy (2-7%)

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