What is the management approach for a patient presenting with fever and seizure?

Management of Fever with Seizure

Immediately administer a benzodiazepine if the seizure is ongoing or lasts more than 5 minutes, then rapidly identify whether this is a simple febrile seizure in a child or a more serious condition requiring urgent intervention. 1, 2

Immediate Seizure Termination

Active Seizure Management

• Administer lorazepam 4 mg IV slowly (2 mg/min) for adults ≥18 years if seizure is ongoing or has lasted >5 minutes 3
• If seizures continue after 10-15 minutes, give an additional 4 mg IV lorazepam slowly 3
• Ensure airway patency is maintained and ventilatory support is immediately available before and during benzodiazepine administration, as respiratory depression is the most important risk 3
• For pediatric patients with ongoing seizures >5 minutes, benzodiazepines should be administered, though specific pediatric dosing requires individualization 1, 2

Second-Line Agents for Refractory Seizures

• If seizures persist despite optimal benzodiazepine dosing, administer fosphenytoin, levetiracetam, or valproate—all have similar efficacy 1
• These three agents show equivalent effectiveness for terminating benzodiazepine-refractory status epilepticus, with no significant differences in safety outcomes 1

Critical Diagnostic Evaluation

Exclude Life-Threatening Causes Immediately

• Perform lumbar puncture if there are any signs of meningism, altered mental status beyond expected post-ictal state, focal neurological deficits, age <18 months (especially <12 months), or if the patient appears systemically ill 1
• The risk of bacterial meningitis in children with first seizure and fever is 2.6%, but drops to 0.2% in apparent simple febrile seizures 4
• In 95% of children >6 months with bacterial meningitis, clinical examination findings will suggest the diagnosis 4
• Check blood glucose immediately in any patient still convulsing or unrousable, as hypoglycemia is a correctable cause 1

Neuroimaging Indications

• Obtain urgent brain imaging if there is: acute head trauma, history of malignancy, immunocompromise, persistent headache, new focal neurological findings, age >40 years, or focal seizure onset 1
• For intracerebral hemorrhage patients with seizures, continuous EEG monitoring ≥24 hours is reasonable if there is unexplained abnormal or fluctuating mental status 1

Context-Specific Management

Simple Febrile Seizures (Children 6 months - 5 years)

• Definition: Brief (<15 minutes), generalized seizure occurring once in 24 hours with fever (≥100.4°F) without CNS infection 1, 2
• Do NOT routinely perform laboratory tests, neuroimaging, or EEG in well-appearing children with simple febrile seizures 1, 2
• Do NOT start prophylactic antiepileptic drugs—neither continuous nor intermittent anticonvulsant therapy is recommended as potential toxicities outweigh the relatively minor risks 1, 5
• Treat the underlying fever source (e.g., antibiotics for otitis media) 6
• Use antipyretics (paracetamol/acetaminophen preferred) for comfort, though they do not prevent seizure recurrence 1, 2

Complex Febrile Seizures

• Definition: Seizure lasting ≥15 minutes, focal features, or recurrence within 24 hours 1, 2
• Risk of bacterial meningitis is 0.6% in apparent complex febrile seizures 4
• Strongly consider lumbar puncture, as the number needed to test to identify one CNS infection is 180 (versus 1109 for simple febrile seizures) 4
• Let the neurological examination guide further evaluation 1

Adult Patients with Intracerebral Hemorrhage

• Administer antiseizure drugs if clinical seizures occur to improve functional outcomes and prevent brain injury from prolonged recurrent seizures 1
• For impaired consciousness with confirmed electrographic seizures, antiseizure drugs should be administered to reduce morbidity 1
• Do NOT use prophylactic antiseizure medication in ICH patients without evidence of seizures—it does not improve functional outcomes, long-term seizure control, or mortality 1

Temperature Management

• Pharmacologically treating elevated temperature in ICH patients may be reasonable to improve functional outcomes, though evidence is limited 1
• Therapeutic hypothermia (<35°C) has unclear benefit for reducing peri-ICH edema 1
• In febrile seizure patients, fever should be treated for comfort and to prevent dehydration, not to prevent seizure recurrence 1

Critical Pitfalls to Avoid

• Do not assume fever with seizure is benign without excluding meningitis—in one-third of pediatric meningitis cases presenting with seizures, meningeal signs may be absent 6
• Do not delay lumbar puncture in children <18 months with fever and seizure, as clinical signs of meningitis are often subtle in this age group 1
• Do not attribute recurrent fevers to pre-existing conditions like AVM or seizure disorder—these do not typically cause chronic recurrent fever patterns and require immediate fever workup 7
• Do not discharge patients with fever, seizure, and severe headache, altered mental status, or focal deficits without emergency evaluation for hemorrhage or infection 7
• Do not use physical cooling methods (cold bathing, tepid sponging, fanning) as they cause discomfort without proven benefit 1

Disposition and Follow-Up

Admission Criteria

• Complex febrile seizures lasting >20 minutes 1
• Failure to return to baseline mental status within 1 hour 1
• Confirmed or suspected CNS infection 1, 6
• Status epilepticus requiring multiple antiepileptic agents 1, 3
• Underlying conditions requiring monitoring (ICH, immunocompromise, malignancy) 1, 7

Discharge Considerations for Simple Febrile Seizures

• Patient has returned to normal baseline 1
• Reliable follow-up is available 1
• Parents have been educated on excellent prognosis and home seizure management 1, 2
• Recurrence risk is 30% overall (higher with younger age at first seizure and positive family history) 1