What is the immediate management for a 2-year-old patient experiencing a seizure with fever, tachypnea, tachycardia, and hypotension?

Immediate Management of a 2-Year-Old with Febrile Seizure

This child requires immediate seizure management if still seizing, airway protection, assessment for sepsis/meningitis given the concerning vital signs, and strong consideration for lumbar puncture given age <18 months.

Acute Seizure Management

If the child is actively seizing or the seizure has lasted >5 minutes, administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min as first-line treatment. 1, 2, 3 When IV access is not available, rectal diazepam should be administered. 1 IM diazepam is specifically not recommended due to erratic absorption. 1

Immediate Supportive Care

• Position the child on their side, protect the head from injury, and remove harmful objects from the environment. 3
• Never restrain the patient or place anything in the mouth during active seizure activity. 1, 3
• Assess and secure airway, breathing, and circulation immediately. 3

Critical Assessment for Serious Bacterial Infection

The vital signs presented (HR 130, RR 28, BP 95/60, temp 102°F) warrant urgent evaluation for sepsis and meningitis, not just simple febrile seizure management. While these vital signs may be within normal limits for a febrile 2-year-old, the clinical context of seizure with fever demands aggressive evaluation.

Immediate Diagnostic Workup

• Measure blood glucose concentration immediately with a glucose oxidase strip in any child who is still convulsing or unrousable. 4
• Perform lumbar puncture given the child's age of 2 years (<18 months threshold). The guidelines state that lumbar puncture should be performed if the child is aged less than 18 months (probably) and almost certainly if aged less than 12 months. 4 Additionally, lumbar puncture is indicated if there are clinical signs of meningism, after a complex convulsion, if the child is unduly drowsy or irritable, or if systemically ill. 4

Important caveat: A comatose child must be examined by an experienced doctor before lumbar puncture because of the risk of coning, and brain imaging may be necessary first. 4

• The decision not to perform lumbar puncture should be reviewed within a few hours if initially deferred. 4
• No other investigations are routinely necessary after a febrile convulsion beyond identifying the source of fever. 4

Seizure Classification and Prognosis

This presentation needs classification as either simple or complex febrile seizure:

• Simple febrile seizures are brief (<15 minutes), generalized, occurring once in 24 hours in children aged 6-60 months with fever ≥100.4°F without CNS infection. 1, 3
• Complex febrile seizures are prolonged (>15 minutes), focal, or occur more than once within 24 hours. 1, 3

If the child has not returned to neurologic baseline within one hour, suspect serious underlying conditions (meningitis, encephalitis, metabolic derangement) and investigate accordingly. 4

Fever Management

• Treat fever with paracetamol (acetaminophen) to promote comfort and prevent dehydration, though antipyretics do not prevent febrile seizures or reduce recurrence risk. 4, 1, 3
• Physical methods such as fanning, cold bathing, and tepid sponging are not recommended as they cause discomfort. 4
• Ensure adequate fluid intake. 4

Disposition and Follow-up

Admit this child if:

• Not returned to neurologic baseline 2, 3
• Concerning neurologic findings on examination 2, 3
• Requires ongoing seizure management 2, 3
• Systemically ill appearance 4
• Confirmed or suspected meningitis/encephalitis

Factors favoring admission after a first convulsion include a complex convulsion lasting longer than 20 minutes, though CT or MRI will usually be performed first in this scenario. 4

Long-term Prophylaxis (NOT Indicated)

Neither continuous nor intermittent anticonvulsant prophylaxis is recommended for simple febrile seizures, as the potential toxicities clearly outweigh the minimal risks. 1, 3 The harm-benefit analysis unequivocally favors no prophylactic treatment. 3 Valproic acid carries risk of rare fatal hepatotoxicity, phenobarbital causes hyperactivity and irritability, and intermittent diazepam causes lethargy and may mask evolving CNS infection. 1, 3

Parent Education

• Simple febrile seizures have excellent prognosis with no long-term adverse effects on IQ, academic performance, or neurocognitive function. 3
• Recurrence risk is approximately 30% overall, with 50% probability in children younger than 12 months at first seizure. 4, 1, 3
• Risk of developing epilepsy is approximately 1%, similar to the general population. 3
• Educate caregivers about practical home management and when to seek emergency care. 1, 3