A 20-month-old boy is brought to the emergency department by ambulance after a single, generalized, tonic-clonic seizure that lasted for approximately 5 minutes. The seizure was witnessed by his grandmother who immediately placed the child onto the floor and turned him on his side. The seizure stopped spontaneously a few minutes prior to the arrival of emergency services. The patient has never had a seizure before. He has had a cough and runny nose for the last 3 days and developed a fever today. His appetite has decreased, but he is drinking and voiding adequately. The patient's vaccinations are up to date, and he takes no daily medications. Developmentally, the patient walks well, can eat with a spoon, and is able to speak 10-15 words. Temperature is 38.7 C (101.7 F), blood pressure is 98/66 mm Hg, pulse is 116/min, and respirations are 28/min. Pulse oximetry is 98% on room air. The child is well appearing and playing quietly with toys. The pupils are equal and briskly reactive to light. Tympanic membranes are clear bilaterally, and posterior pharynx is injected slightly without exudate. The neck is supple. Cardiopulmonary examination is normal. Muscle tone is normal and strength is full bilaterally. Deep tendon reflexes are 2+ and symmetric in the upper and lower extremities. There are no rashes or petechiae. An antipyretic is administered, and his temperature decreases to 37.8 C (100 F). Which of the following is the best next step in management of this patient?

Question

A 20-month-old boy is brought to the emergency department by ambulance after a single, generalized, tonic-clonic seizure that lasted for approximately 5 minutes.  The seizure was witnessed by his grandmother who immediately placed the child onto the floor and turned him on his side.  The seizure stopped spontaneously a few minutes prior to the arrival of emergency services.  The patient has never had a seizure before.  He has had a cough and runny nose for the last 3 days and developed a fever today.  His appetite has decreased, but he is drinking and voiding adequately.  The patient's vaccinations are up to date, and he takes no daily medications.  Developmentally, the patient walks well, can eat with a spoon, and is able to speak 10-15 words.  Temperature is 38.7 C (101.7 F), blood pressure is 98/66 mm Hg, pulse is 116/min, and respirations are 28/min.  Pulse oximetry is 98% on room air.  The child is well appearing and playing quietly with toys.  The pupils are equal and briskly reactive to light.  Tympanic membranes are clear bilaterally, and posterior pharynx is injected slightly without exudate.  The neck is supple.  Cardiopulmonary examination is normal.  Muscle tone is normal and strength is full bilaterally.  Deep tendon reflexes are 2+ and symmetric in the upper and lower extremities.  There are no rashes or petechiae.  An antipyretic is administered, and his temperature decreases to 37.8 C (100 F).  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bff4_bb15_8f63_2f307a8e35b5_MD0005_00 This child had a febrile seizure, a common complication of high fevers that usually develops from a mild viral infection (eg, common cold). Febrile seizures frequently affect children age 3 months to 6 years. The seizures are typically nonfocal, last <15 minutes, and do not occur more than once per day. Patients with febrile seizures have no previous afebrile seizure, no evidence of metabolic disease (eg, asterixis, depressed sensorium), and no signs of intracranial infection (eg, neck stiffness, bulging fontanelles, photophobia). Febrile seizures are clinically diagnosed and further evaluation is typically not indicated. Parents should be provided reassurance that febrile seizures are common and usually self-resolve without acute or long-term sequelae. Antipyretics are administered for general fever reduction, but parents should be informed that they do not prevent future episodes of febrile seizures. (Choice A) Although this patient has a fever, he appears well and has viral upper respiratory tract infection symptoms (eg, cough, rhinorrhea); therefore, hospitalization and antibiotics are not indicated. (Choice B) An electroencephalogram (EEG) may be indicated in patients with atypical seizures (eg, multiple, focal) or with abnormal neurologic examinations (eg, abnormal reflexes, developmental delay). This child has a normal neurologic examination and no atypical features; therefore, an EEG is not indicated. In addition, EEG results do not alter long-term outcome. (Choice C) This child does not require lumbar puncture as there are no clinical features suggestive of meningitis (eg, meningismus), and vaccinations against Haemophilus influenzae type b and Streptococcus pneumoniae are current. (Choice D) Abortive antiepileptic drugs should be considered for any patients with febrile or afebrile seizures lasting >5 minutes due to the risk of cardiorespiratory compromise. However, most febrile seizures resolve spontaneously, as in this case. In addition, abortive antiepileptic drugs do not alter the outcome of a child who has had a febrile seizure, even with an abnormal EEG. Educational objective: Febrile seizures are benign complications of infection that are diagnosed clinically. Patients with this presentation have a favorable prognosis and no acute or long-term sequelae; therefore, management is typically to provide reassurance. References: Evaluation and management of pediatric febrile seizures in the emergency department. (http://www.ncbi.nlm.nih.gov/pubmed/21109105) Update on the management of simple febrile seizures: emphasis on minimal intervention. (http://www.ncbi.nlm.nih.gov/pubmed/22327951)

A 20-Month-Old Boy Is Brought to the Emergency Department by Ambulance