What is the management of febrile status epilepticus in children?

Management of Febrile Status Epilepticus in Children

Immediate Acute Management

For febrile status epilepticus (seizure lasting >5 minutes), immediately administer lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) at 2 mg/min as first-line treatment while simultaneously assessing airway, breathing, and circulation. 1

Initial Stabilization Steps

• Position the child on their side in recovery position to prevent aspiration and clear the surrounding area of harmful objects 1, 2
• Never restrain the patient or place anything in the mouth during active seizure activity 1, 3
• Protect the head from injury during convulsive movements 1

Medication Administration Algorithm

When IV access is available:

• First-line: Lorazepam 0.05-0.1 mg/kg IV (maximum 4 mg) given slowly at 2 mg/min 1
• Alternative: IV diazepam if lorazepam unavailable 3

When IV access is NOT available:

• Rectal diazepam should be administered immediately 3
• IM phenobarbital may be considered only when rectal diazepam is not feasible due to medical or social reasons 3
• Avoid IM diazepam due to erratic absorption 3

Critical Timing Considerations

• Median time from seizure onset to first AED administration is typically 30 minutes, but earlier treatment significantly reduces total seizure duration 4
• Reducing time from seizure onset to AED initiation is the most important modifiable factor affecting outcome 4
• Median time from first AED dose to seizure termination is 38 minutes, indicating that febrile status epilepticus is fairly medication-resistant 4

Refractory Febrile Status Epilepticus

If seizures persist after initial benzodiazepine administration, 70% of children will require multiple AEDs for seizure termination. 4

Advanced Management Strategy

• For convulsive refractory febrile status epilepticus, barbiturate coma therapy with continuous EEG monitoring and targeted temperature management (maintaining normothermia) achieves superior neurological outcomes compared to midazolam without EEG monitoring 5
• The titration goal should be suppression or burst-suppression patterns on continuous EEG, not merely clinical seizure cessation 5
• Maintain normothermia using blankets and neuromuscular blockade rather than relying solely on antipyretics 5
• Consider ketogenic diet and aggressive immunomodulatory therapy for febrile infection-related epilepsy syndrome (FIRES) 6

Important Pitfall

• Clinical seizure control using midazolam without continuous EEG monitoring or targeted temperature management is insufficient in preventing neurological damage - 50% of children treated this way had poor outcomes versus 0% with barbiturate coma plus EEG monitoring 5

Respiratory Support

• Approximately 48% of children with febrile status epilepticus require respiratory support by EMS or ED 4
• Children requiring respiratory support have longer median seizure duration (83 minutes vs 58 minutes) 4
• Barbiturate coma therapy patients should be routinely intubated 5

Long-Term Management and Prophylaxis

Neither continuous nor intermittent anticonvulsant prophylaxis should be used for children with febrile seizures, including those who have experienced febrile status epilepticus, as the potential toxicities clearly outweigh the minimal risks. 1, 3

Why Prophylaxis is Not Recommended

• Prophylactic anticonvulsants do not prevent the development of epilepsy later in life 1, 7
• Valproic acid carries risk of rare fatal hepatotoxicity, thrombocytopenia, and pancreatitis, especially in children younger than 2 years 1
• Phenobarbital causes hyperactivity, irritability, lethargy, sleep disturbances, and reduces IQ by mean of 7 points during treatment 1
• Intermittent diazepam prophylaxis may reduce recurrence but does not improve long-term outcomes and causes lethargy and ataxia 1, 7

Exception for Complex Febrile Seizures

• For complex febrile seizures (prolonged, focal, or multiple within 24 hours), intermittent diazepam during febrile illness may be considered, though evidence for improved outcomes is lacking 3, 7

Home Rescue Medication Option

• An attractive alternative is rectal diazepam solution given by parents at seizure onset to prevent progression to febrile status epilepticus 7
• This strategy focuses on short-term seizure control rather than prevention of recurrence 7

Diagnostic Evaluation

Lumbar Puncture Indications

• Children under 12 months of age with fever and seizure should undergo lumbar puncture to rule out meningitis, as meningeal signs may be absent in up to one-third of cases 1

Neuroimaging

• Routine neuroimaging is NOT indicated for simple febrile seizures 1, 2
• For febrile status epilepticus or complex febrile seizures, neuroimaging may be considered only when postictal focal neurological deficits are present, underlying pathology is suspected, or concern for intracranial pathology exists 2
• Brain MRI abnormalities occur in 11.4-14.8% of children but do not alter clinical management 2

EEG

• EEG is explicitly an inappropriate investigation for simple febrile seizures and should not be performed 1
• Continuous EEG monitoring is essential for managing refractory febrile status epilepticus to guide anesthetic titration 5

Prognosis and Parent Education

• Simple febrile seizures cause no decline in IQ, academic performance, neurocognitive function, or structural brain damage 1, 2
• Risk of developing epilepsy after simple febrile seizures is approximately 1%, identical to the general population 1, 3
• Febrile status epilepticus has been linked to subsequent development of focal epilepsy, though it is neither necessary nor sufficient - multiple insults are likely required 8
• Recurrence risk is approximately 30% overall, with 50% probability in children younger than 12 months at first seizure 1, 2

Key Counseling Points

• Educate caregivers about the generally benign nature of febrile seizures and excellent prognosis 1, 3
• Antipyretics (acetaminophen, ibuprofen) do not prevent febrile seizures or reduce recurrence risk, though they may improve comfort 1, 3, 7
• Activate emergency services for first-time seizures, seizures lasting >5 minutes, multiple seizures without return to baseline, or seizures with traumatic injuries or breathing difficulties 3, 2