Febrile convulsions and new onset seizures

Seizures in the paediatric setting has appeared twice in the CICM fellowship exam:

• Question 19 from the second paper of 2022, which was all about the assessment and management of an eight year old having their first generalised seizure
• Question 5 from the first paper of 2014 where febrile convulsions became the subject of detailed interrogation

These are obviously completely different from an aetiological standpoint, but the Venn diagrams do overlap somewhat, and so it seemed reasonable to combine them all into the same chapter.

New seizures in a child

Question 19 from the second paper of 2022 gives no context other than"an 8-year-old child having their first generalized seizure", which makes you think that, when it asks for initial assessment and management, only the most generic responses were required. Also, "having" suggests "they are having it right now in front of you". Thus:

• Resuscitation
  • Administer oxygen
  • Secure the airway if it is unprotected
  • Achieve IV access, collect a routine panel of blood samples including blood cultures,  and administer IV benzodiazepines
• Assessment
  • History from parents
    • Provoking factors (medications, toxins, metabolic factors eg. diabetes and DKA, recent illness, trauma)
    • Predisposing factors (eg. brain injury, cerebral palsy, congenital abnormalities)
    • Behaviour immediately prior to the event (eg. aura)
  • Examination findings
    • Seizure vs. other causes of decreased level of consciousness with rigidity or abnormal movements (eg. cardiac event such as arrhythmia, followed by syncope)
    • Focal neurological signs pointing to intracranial pathology
    • Features of sepsis (eg. febrile convulsion)
    • Meningism 
    • Features suggestive of non-convulsive status (eg. dilated pupils, rigidity, clonus)
    • Systemic features suggestive of autoimmune disease or vasculitis
    • General examination/inspection findings suggestive of congenital abnormalities
• Investigations
  • Biochemistry
    • Normal bloods (BSL/FBC/EUC/CMP/LFT/coags) as well as ammonia level, and serum 
  • Electrophysiology
    • EEG, including awake and sleeping
  • Imaging
    • ​​​​​​​CT brain (ideally also involving contrast)
    • Lumbar puncture 
    • MRI brain
• Medium-term management
  • Antiepileptic agents:
    • Initially, and while being worked up: benzodiazepines
    • For focal seizures—carbamazepine, clobazam (especially children), gabapentin, lamotrigine, oxcarbazepine, topiramate, valproate x
    • For generalised seizures—Levitiracetam, lamotrigine, topiramate, valproate.
  • Parents: counselling, specifically re. implications of epilepsy (if this is in fact the diagnosis)

Febrile convulsions

By the most recently attempted definition, febrile convulsions are "a seizure occurring in childhood after one month of age, associated with a febrile illness that is not caused by an infection of the central nervous system". There are actually two definitions, which differ slightly. In brief summary, these are seizures which occur in the presence of fever and in the absence of any other good reason for seizures, in an age range variably described as under 6 years, 1 month to five years, 3 months to five years, and six months to six years.

The Royal Children's Hospital Clinical Guidelines has a slightly different age range to both of the above, and closely resembles the college answer. Clearly, both must have the same source.

The list of criteria for the diagnosis of simple febrile convulsions:

• Fever >38.0°
• No history of neonatal seizures
• No previous unprovoked seizures
• No focal neurological features (i.e. generalised seizure)
• Tonic-clonic seizure
• Occurs after 6 months of age, and before the age of 6
• Lasts less than 15 minutes
• Occurs only once per episode of febrile illness.

Additionally, the following is a list of criteria for the diagnosis of complex febrile convulsions:

• Focal seizure (focal features at onset or during the seizure)
• Lasts longer than 15 minutes
• Occurs several times within the same episode of febrile illness.
• Incomplete recovery after 1 hour.

In Question 5 from the first paper of 2014, the college asked for five drugs with which to manage seizures in the paediatric population – one from each class, as well as their dose, their advantages and disadvantages. Such a question lends itself well to a tabulated answer.

Much of this information can be found it its raw untreated form in Slater's chapter on neurological emergencies in children, from Oh's Manual.