Fits/Seizures Station

Presenting Complaint: Sudden episode of generalised shaking and loss of consciousness

• Quote from patient’s father: “He was fine earlier, then I saw his body go stiff and his eyes rolled back - I was so scared. He has also had a really high temperature.”

Symptoms:

• Site: Generalised body - "It was all over his body, like he was stiff and shaking everywhere."
• Onset: Sudden - "It just started out of nowhere today while he was playing."We came straight away to the hospital after it happened. 
• Character: Tonic-clonic - "He went stiff and then started shaking like he couldn’t control his body."
• Radiation: No radiation - "It was just his whole body shaking."
• Associated Symptoms: Fever - "He had a high temperature recently and he was feeling tired afterwards for a little bit and not as active as he usual.”
• Timing: 1-2 minutes - "It lasted for about a minute or so, then he stopped shaking."
• Exacerbating and Relieving Factors: “Paracetamol helped to bring the temperature down but the shaking stopped on its own.”
• Severity: Severe - "It was really scary; he didn’t respond at all during the shaking."

Systemic Symptoms:

• Fatigue: No
• Fever: Yes, prior to seizure.
• Night Sweats: No
• Unintended Weight Loss: No
• Chest or Shoulder Tip Pain: No
• Shortness of Breath or Cough: No
• Oedema: No
• Rashes or Skin Changes: No
• Headache: No
• Mood Changes: No
• Sleep Disturbances: No
• Change in Bowel Habits: No
• Urinary symptoms: No

Past Medical History:

• No history of febrile convulsions in the past.
• No history of epilepsy or neurological or developmental conditions.

Birth History:

• Born 40 weeks gestation.
• Vaginal delivery.
• No complications during pregnancy. 
• Did not require admission into neonatal unit.

Development: no concerns with achieving developmental stages. 

Immunisations: up to date with his immunisations.

Feeding: currently breast-fed but is also able to tolerate some soft food, although is quite a picky eater.

Allergies:

• No known drug allergies.

Family History:

• No family history of seizures or neurological disorders.

Social History:

• Lifestyle: Lives with both parents in an urban area.
• Occupation: Both parents are working full-time, and child attends daycare with other children.
• Hobbies/ADLs: Plays actively with peers, enjoys playing with toys.
• Pets at home: None.

Ideas, Concerns, and Expectations:

• Ideas:
  • "I don’t know what caused this. I thought convulsions were only for really sick kids."
• Concerns:
  • "I’m worried it might happen again, and he could get hurt."
  • "Should I worry about brain damage or something more serious?"
• Expectations:
  • "I hope it’s something simple that can be treated, and I want to know if there’s anything I can do to prevent it from happening again."

• Observations:

   

  

  NHS Scotland Paediatric Early Warning Scores

   

  • Respirations (Breaths/min): 20
  • Oxygen Saturation (%): 98% on room air
  • Air or Oxygen?: Room air
  • Blood Pressure (mmHg): 100/65
  • Pulse (Beats/min): 110
  • Consciousness (AVPU): Alert (after postictal period)
  • Temperature (Celsius): 38.8°C
  • PEWS Total Score: 2

  
  
  

  Physical Examination:

  • General Inspection:
    • The child is alert but slightly subdued.
    • No obvious distress after seizure, appears settled.
    • No signs of trauma or injury.
    • No obvious rashes.

   

  • Hands:
    • No tremors or cyanosis.
    • Capillary refill time: <2 seconds.

   

  • Arms:
    • No signs of trauma, excoriations, or bruises.

   

  • Face:
    • No jaundice, cyanosis or pallor.
    • Fontanelle closed.
    • No grunting or signs of respiratory distress e.g. head bobbing.
    • No apparent head injury.

   

  • Neck:
    • No lymphadenopathy.
    • No accessory respiratory muscle use.
    • No nuchal rigidity.

   

  • Chest:
    • Normal chest expansion and breath sounds.
    • No intercostal retractions.
    • No abnormal heart sounds.
    • No rash.

   

  • Abdomen:
    • No tenderness or masses.
    • No organomegaly.
    • No rash.

   

  • Other:
    • No peripheral oedema or signs of malnutrition.
    • Neurology grossly normal.
    • Kernig and Brudzinski sign negative.

  

  Kernig and Brudzinski signs

Answer EITHER viva questions OR patient questions:

Patient Questions:

1."What exactly causes these convulsions? Can it happen again?"

• Possible answer: Febrile seizures are triggered by a rapid increase in body temperature, usually in younger children, often from a viral infection. Because it has happened once, there is about a 1 in 3 chance it will happen again with subsequent fevers. However, they typically resolve with no long-term effects.

2."Could this be something serious like epilepsy or brain damage?"

• Possible answer: Febrile seizures are usually not related to epilepsy or brain damage. Most children outgrow them, and they do not result in lasting harm. They do very slightly increase the risk of developing epilepsy compared to the general population, but the risk is still very small at under 5% following a simple febrile seizure, and this does not require treatment with antiepileptic medication.

3."How can I prevent this from happening again?"

• Possible answer: Keep the child’s fever under control with antipyretics such as paracetamol and ensure they stay well-hydrated. If another seizure occurs, protect the child from physical injury during the seizure and seek immediate medical help if the seizure lasts for more than 5 minutes. We can provide you with a patient information leaflet, some simple first aid instructions and discuss a personalised seizure plan.

Examiner Questions:

1.Based on the history taken, what is your main diagnosis and some differentials? 

Answer: Febrile convulsions is the most likely diagnosis given the child’s age and preceding history of fever, which is confirmed on the observations. It is a common cause of seizures in this age group and is diagnosed clinically.

Other possible differentials include:

• Epileptic seizure - less likely here due to the history of fever 
• Bacterial meningitis - in meningitis the child would likely appear more unwell clinically, possibly with other indicative signs such as abnormal neurology, nuchal stiffness, non-blanching rash, irritability and lethargy.
• Viral meningitis or encephalitis - would likely present more unwell with irritability, lethargy, neck stiffness, headache and photophobia +/- rash.

2.What advice should be given to parents if seizures happen again?

• Answer: Ensure the child is safe from injury, place them on their side, and monitor their airway and breathing. After the seizure, assess temperature and provide antipyretics if necessary. If the seizure lasts more than 5 minutes to contact help/999 as may need to follow the status epilepticus guidelines which include giving rescue medications.

3.When would you consider further investigation, such as a lumbar puncture or brain imaging?

• Answer: If the child has an abnormal neurological exam or signs of meningitis such as neck stiffness, non-blanching rash, or suggestive features in the history such as incomplete immunisation, or the seizure lasts longer than 5 minutes, further investigation is warranted. Otherwise, no additional tests are needed for a simple febrile seizure as it is predominantly a clinical diagnosis.

4.How are febrile seizures generally classified, and how would you differentiate between these?

• Answer: Febrile seizures can be classified into simple and complex febrile seizures. Simple febrile seizures are usually short-lasting, tonic-clonic in nature and may include tongue biting and incontinence during the episode. Parents may also describe abnormal eye movements such as eye rolling. 
• Complex febrile seizures are characterised by duration more than 15 minutes, multiple seizures within 24 hours, or features suggestive of a focal seizure (usually unilateral/affecting different parts of the lobe). ​​These may be managed with antiepileptics and consideration for referral to a paediatrician. The risk of developing non-febrile seizures and epilepsy after simple febrile seizures is 5% or less. However, after complex febrile seizures, the risk of developing epilepsy is 10%-20%.