What is the management approach for an 18-month-old female presenting with a focal seizure and hyperthermia (fever) of 103 degrees Fahrenheit?

Management of Febrile Seizure in an 18-Month-Old Child

For an 18-month-old female presenting with a focal seizure and fever of 103°F, immediate management should include antipyretic therapy, assessment for signs of meningitis, and strong consideration for lumbar puncture due to the focal nature of the seizure. 1

Initial Assessment and Stabilization

• Ensure patent airway, breathing, and circulation
• Monitor oxygen saturation and vital signs (temperature, heart rate, respiratory rate, blood pressure)
• If seizure is ongoing:
  • Administer benzodiazepine: IV lorazepam (0.1 mg/kg, maximum 4 mg) or rectal diazepam
  • Check blood glucose with glucose oxidase strip if child is still convulsing or unrousable 2

Fever Management

• Administer acetaminophen (paracetamol) for fever control
• Ensure adequate hydration
• Avoid physical cooling methods like cold bathing or tepid sponging 2, 1
• Monitor temperature regularly

Infection Assessment

Critical Decision Point: Lumbar Puncture

Lumbar puncture is strongly indicated in this case due to:

• Focal seizure (complex febrile seizure)
• Age less than 18 months 2, 1

Other indications for lumbar puncture include:

• Clinical signs of meningitis
• Unduly drowsy or irritable child
• Child who is systemically ill 2

Additional Investigations to Consider

• Complete blood count
• Blood culture if clinically indicated
• Electrolytes if indicated by history or physical exam
• Thorough examination for source of infection (ears, throat, chest, urine) 1

Neuroimaging and EEG

• Consider neuroimaging (CT or MRI) due to the focal nature of the seizure, especially if there is:
  • Persistent altered mental status
  • Focal neurological deficits
  • Concern for increased intracranial pressure 1
• EEG is not routinely recommended after a first febrile seizure 2, 1

Hospital Admission Criteria

This child should be admitted to hospital based on:

• Complex febrile seizure (focal seizure)
• Age less than 18 months
• Need for observation and possible further investigation 1

Parent Education

• Explain the nature of febrile seizures and their generally benign prognosis
• Discuss the risk of recurrence (approximately 30% overall)
• Provide instructions on fever management and seizure first aid
• Consider teaching parents to administer rectal diazepam for prolonged seizures 2, 1

Prognosis and Follow-up

• Risk of developing epilepsy after a complex febrile seizure is higher than with simple febrile seizures but still relatively low (approximately 2.5-10%) 1
• Arrange follow-up with primary care physician and consider neurology referral given the focal nature of the seizure 1

Common Pitfalls to Avoid

1. Failing to consider meningitis in a young child with a focal seizure and fever
2. Omitting lumbar puncture in a child under 18 months with a complex febrile seizure
3. Unnecessary routine EEG or neuroimaging in all cases of febrile seizures
4. Overuse of prophylactic anticonvulsants (not recommended for most febrile seizures)
5. Inadequate parent education about febrile seizure management and recurrence risk

The focal nature of this seizure, combined with the young age of the patient, necessitates a more thorough evaluation than would be required for a simple febrile seizure, with particular attention to ruling out central nervous system infection.