What is the initial management and workup for a patient presenting with new onset seizures and fever?

From the Guidelines

Initial management of a patient with new onset seizures and fever should prioritize stabilizing the patient, controlling seizures, and identifying the underlying cause, with a focus on ruling out life-threatening conditions such as meningoencephalitis, as suggested by the Infectious Diseases Society of America guidelines 1. The first step is to ensure airway, breathing, and circulation are secure. Administering benzodiazepines such as lorazepam (0.1 mg/kg IV) or diazepam (0.15-0.2 mg/kg IV) is crucial to stop ongoing seizures. For persistent seizures, consider phenytoin (20 mg/kg IV) or levetiracetam (60 mg/kg IV, max 4500 mg). Fever should be treated with antipyretics like acetaminophen (15 mg/kg/dose) or ibuprofen (10 mg/kg/dose). The diagnostic workup should include:

• A complete blood count
• Comprehensive metabolic panel
• Blood glucose
• Blood cultures
• Toxicology screen Lumbar puncture is essential to rule out meningitis or encephalitis, with CSF analysis for cell count, protein, glucose, culture, and PCR for herpes simplex virus. According to the most recent guidelines on optimizing advanced imaging of the pediatric patient in the emergency department, noncontrast MRI is generally the preferred imaging modality for stable patients, although noncontrast CT is acceptable if MRI is not readily available 1. Empiric antibiotics (ceftriaxone 2g IV q12h plus vancomycin 15-20 mg/kg IV q8-12h) and acyclovir (10 mg/kg IV q8h) should be started promptly if central nervous system infection is suspected, as delayed treatment can lead to permanent neurological damage. Key considerations in the management include:
• Rapid diagnosis and treatment of potentially life-threatening conditions
• The use of advanced imaging modalities such as MRI or CT to identify structural abnormalities
• The importance of lumbar puncture and CSF analysis in diagnosing meningitis or encephalitis
• The role of empiric antibiotics and antiviral medications in managing suspected central nervous system infections.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Initial Management and Workup

The initial management and workup for a patient presenting with new onset seizures and fever involve a comprehensive approach to determine the underlying cause of the seizures.

• Extensive testing of blood and CSF for infectious, rheumatologic, and metabolic conditions, neuroimaging, EEG, autoimmune/paraneoplastic antibody evaluations, malignancy screen, genetic testing, and CSF metagenomics may reveal the etiology in some patients 2.
• Management of seizures in the initial 24-48 hours should be like any case of refractory status epilepticus, with first-line immunotherapy beginning within 72 hours using steroids, intravenous immunoglobulins, or plasmapheresis 2.

Diagnostic Considerations

• Febrile seizure (FS) is a common form of childhood seizure disorders, and the diagnosis and management of FS should be individualized, taking into account specific 'warning factors' 3.
• Complex febrile seizures may require emergent neuroimaging, especially if the patient has a focal neurological deficit or appears unwell 4.
• A differential diagnosis should include various types of seizures, and the implementation of pharmacologic therapies as well as ongoing care of the patient should be considered 5.

Treatment Options

• Intermittent oral levetiracetam can effectively prevent febrile seizure recurrence and reduce medical resource utilization 6.
• The ketogenic diet and second-line immunotherapy should start within seven days if there is no improvement with first-line treatment 2.
• Rituximab is recommended as the second-line treatment if there is a strong suggestion or proof of an antibody-mediated disease, while anakinra or tocilizumab are recommended for cryptogenic cases 2.