A 2-year-old boy is brought to the emergency department by ambulance due to convulsions. This morning, the patient was sitting on the sofa at home when he suddenly developed rhythmic movements of both arms and legs that lasted about 3 minutes. He was not responsive during the event. Emergency personnel report that the child was sleepy and seemed confused when they arrived. The patient has had rhinorrhea for the past 2 days and fever since this morning. He has had no cough, vomiting, or diarrhea. The patient has no chronic medical conditions, and immunizations are current. His uncle has epilepsy. Temperature is 39.2 C (102.6 F). Physical examination shows an alert and playful toddler. Bilateral conjunctivae are clear, and clear rhinorrhea is present. The neck is supple with full range of motion. Mucous membranes are moist, and capillary refill is

Question

A 2-year-old boy is brought to the emergency department by ambulance due to convulsions.  This morning, the patient was sitting on the sofa at home when he suddenly developed rhythmic movements of both arms and legs that lasted about 3 minutes.  He was not responsive during the event.  Emergency personnel report that the child was sleepy and seemed confused when they arrived.  The patient has had rhinorrhea for the past 2 days and fever since this morning.  He has had no cough, vomiting, or diarrhea.  The patient has no chronic medical conditions, and immunizations are current.  His uncle has epilepsy.  Temperature is 39.2 C (102.6 F).  Physical examination shows an alert and playful toddler.  Bilateral conjunctivae are clear, and clear rhinorrhea is present.  The neck is supple with full range of motion.  Mucous membranes are moist, and capillary refill is <2 seconds.  The remainder of the examination is normal.  After treating the fever with acetaminophen, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d5ec_de45_bc81_b50f9f390f2e_MD0003_00 Febrile seizures are common and generally benign convulsions that occur in the setting of a fever ≥38 C (100.4 F) in children age 6 months to 5 years. Risk factors include high fever (typically from a viral illness), recent immunization, and a family history of febrile seizures. Simple febrile seizures are characterized by generalized tonic-clonic movements lasting <15 minutes. Patients may have a postictal period (eg, drowsiness) but typically return to baseline within minutes. Neurologic examination is normal, and simple febrile seizures do not recur within 24 hours. Diagnosis is clinical, and no further evaluation is required. Patients can be discharged home with reassurance and supportive care (eg, antipyretics). Families should be educated that febrile seizures often recur (in 30% of patients) and that although the risk of epilepsy is slightly increased, overall risk remains low (~1%). Antipyretics do not reduce the risk of future febrile seizures. (Choice A) Brain imaging should be performed for patients with febrile seizure who have focal neurologic signs. (Choices B and D) Electroencephalography (EEG) is indicated for recurrent, unprovoked seizures to diagnose underlying epilepsy syndromes. Levetiracetam is a common, first-line antiepileptic medication. Because simple febrile seizures are typically benign with no long-term sequelae, neither EEG nor antiseizure medication is recommended. (Choice C) Hospitalization and observation are required in a patient who has not returned to neurologic baseline following a seizure. (Choice E) Lumbar puncture for febrile seizure should be considered in patients with persistent neurologic abnormalities, in those already on antibiotics that could mask signs/symptoms of meningitis, and in infants age 6-12 months with incomplete immunization against Streptococcus pneumoniae or Haemophilus influenzae type b. (Choice G) Severe vomiting and diarrhea can lead to metabolic derangements (eg, hypoglycemia, hyponatremia) in addition to dehydration and possibly seizure. This patient has had no gastrointestinal symptoms and appears well hydrated, making serum electrolyte testing unwarranted. Educational objective: Simple febrile seizures are typically benign and occur in children age 6 months to 5 years. They are generalized, last <15 minutes, and do not recur within 24 hours. Diagnostic testing is unnecessary, and management is with supportive care (eg, antipyretics) and reassurance. References: Neurodiagnostic evaluation of the child with a simple febrile seizure. (http://www.ncbi.nlm.nih.gov/pubmed/21285335) Febrile seizures. (http://www.ncbi.nlm.nih.gov/pubmed/24484859) Update on the management of simple febrile seizures: emphasis on minimal intervention. (http://www.ncbi.nlm.nih.gov/pubmed/22327951)

A 2-Year-Old Boy Is Brought to the Emergency Department by Ambulance