What is the acute management of febrile status epilepticus in a child?

Management of Febrile Status Epilepticus in Children

Immediate Stabilization and First-Line Treatment

Begin with airway, breathing, and circulation assessment, provide high-flow oxygen, check blood glucose, and immediately administer lorazepam 0.1 mg/kg IV (maximum 2 mg) as first-line treatment, repeating after at least 1 minute if seizures persist (maximum 2 doses). 1

• Position the child on their side, remove harmful objects, and protect the head from injury 2
• Never restrain the patient or place anything in the mouth during active seizure activity 2
• Transfer immediately to the pediatric intensive care unit (PICU) for convulsive status epilepticus 1
• The median time from seizure onset to first antiepileptic drug (AED) administration is typically 30 minutes, but earlier treatment significantly reduces total seizure duration 3

Second-Line Treatment

If seizures persist after benzodiazepines, immediately administer levetiracetam 40 mg/kg IV bolus (maximum 2,500 mg) in addition to maintenance dosing. 1

• This should be given concurrently with the benzodiazepine protocol, not sequentially 1
• Febrile status epilepticus rarely stops spontaneously and is fairly resistant to medications, with mean seizure duration of 81-95 minutes even with treatment 3

Third-Line Treatment for Refractory Seizures

Add phenobarbital IV at a loading dose of 10-20 mg/kg (maximum 1,000 mg) if seizures persist despite benzodiazepines and levetiracetam. 1

• Approximately 70% of children with febrile status epilepticus require more than one AED to terminate seizures 3
• The median time from first AED dose to seizure termination is 38 minutes 3
• Continuous EEG monitoring is essential if seizures remain refractory 1

Respiratory Support

• Anticipate the need for respiratory support in approximately 48% of cases 3
• Children requiring respiratory support have significantly longer seizure duration (median 83 minutes vs. 58 minutes without support, p<0.001) 3
• This reflects seizure severity rather than treatment complications 3

Maintenance Therapy After Seizure Termination

Following resolution of status epilepticus, administer maintenance doses: 1

• Lorazepam 0.05 mg/kg (maximum 1 mg) IV every 8 hours for 3 doses 1
• Levetiracetam 30 mg/kg IV every 12 hours or increase prophylaxis dose by 10 mg/kg (to 20 mg/kg) IV every 12 hours (maximum 1,500 mg) 1
• Phenobarbital 1-3 mg/kg IV every 12 hours if used 1

Critical Pitfalls to Avoid

• Suboptimal initial benzodiazepine dosing occurs in 19% of cases—ensure weight-based dosing is accurate 3
• Do not delay treatment waiting for IV access; earlier onset of treatment results in significantly shorter total seizure duration 3
• The total seizure duration comprises two factors: time from onset to AED initiation and time from first AED to termination—reducing the first interval is critical 3

Long-Term Prognosis and Follow-Up

• Acute hippocampal injury (visible as T2 hyperintensity on MRI) occurs in approximately 10% of febrile status epilepticus cases 4
• Children with acute hippocampal T2 hyperintensity have a 71% 10-year cumulative incidence of epilepsy and 39% risk of medial temporal lobe epilepsy 4
• Those with completely normal acute MRI have only 23% epilepsy risk and essentially no risk of temporal lobe epilepsy 4
• Neurologically normal children who experience febrile status epilepticus do not have significantly increased risk for subsequent febrile or afebrile seizures compared to brief febrile seizures 5
• However, neurologically impaired children with febrile status epilepticus have 66% risk of recurrent febrile seizures and 33% risk of recurrent febrile status epilepticus 5

Special Consideration: FIRES (Febrile Infection-Related Epilepsy Syndrome)

• If refractory status epilepticus develops 24 hours to 2 weeks after a febrile illness, consider FIRES—a distinct entity requiring immunomodulatory treatment including ketogenic diet, IV corticosteroids, and IV immunoglobulin 6, 7
• FIRES has poor prognosis with significant cognitive disability and refractory epilepsy 6

Post-Acute Management

Do NOT prescribe continuous or intermittent anticonvulsant prophylaxis for simple or complex febrile seizures following resolution of status epilepticus, as the risks clearly outweigh benefits. 2, 8

• Antipyretics (acetaminophen, ibuprofen) should be used for comfort only, not seizure prevention, as they do not reduce recurrence risk 2, 8