Febrile Seizure v.1.

1: ED Management
Executive Summary

Explanation of Evidence Ratings

Test Your Knowledge

Summary of Version Changes

Inclusion Criteria
Patients age 6-60 months with seizure
AND fever 38C or parental report of
fever within 24 hours

Exclusion Criteria
Known epilepsy, probable intracranial
infection, intracranial shunt,
immunodeficiency, cardiac right-to- left
shunt, or oncology patients

PHASE I (E.D.)

If Actively Seizing, Use ED Seizure (Status Epilepticus) Orderset

Signs and Symptoms of Meningitis or Intracranial Infection

No

Assess
Meningitis or
or Intracranial
Intracranial Infection
Infection
AssessRisk
Riskfor
of Meningitis
Physical Signs
Petechiae
Questionable nuchal rigidity
Drowsiness
Convulsing on examination
Weakness or neurological deficit on
examination
Signs of infection of head or neck with
potential for intracranial extension
(such as mastoiditis, sinusitis, etc.)
Bulging fontanelle

History
>3 days duration of illness
Seen by primary MD in previous 24
hours
Drowsiness or vomiting at home
Infant 6-12 months old deficient in
Hib or pneumococcal vaccines or
immunization status cannot be
determined
Pretreated with antibiotics

Clinical judgement of
low risk

Meningitis Less Likely

Prior febrile seizure
Pre-existing neurological
findings

Clinical judgement of
significant risk

Acute
Acute Evaluation
Evaluation
Lab testing should focus on finding the cause of the patients
fever
Routine analysis of serum electrolytes, calcium, phosphorus,
complete blood count and blood glucose are not
recommended, unless they are indicated by a suspicious
history or physical findings.
Gastroenteritis
If vomiting and/or diarrhea, refer to Acute Gastoenteritis
Pathway
Blood glucose level and urine drug screen may be
considered useful if the child does not return to baseline
mental status or regain consciousness after the seizure.
Consider neurology consultation if new prolonged focal
neurologic deficit with suspicion of subclinical status
epilepticus or seizure duration > 30 minutes
EEG or neuroimaging not recommended for routine
evaluation

Complex Features
Focal seizures
Seizure duration >15 minutes
Multiple seizures in 24 hours

Evaluate for Meningitis

or Intracranial Infection

No
meningitis

Consider CT if concern for increased intracranial

pressure
Lumbar Puncture
Labs: CBC, blood culture, glucose
Treat with empiric antibiotics

Meningitis present

Off
Pathway

Assess admit and discharge criteria

ED Discharge Criteria
Cause of fever does not require inpatient admission
Patient appears non-toxic and returns to
neurological baseline
If complex febrile seizure: observe 2 hours after
seizure
Parental anxiety addressed
Parental education provided
Appropriate outpatient follow-up is identified
Safe transport home arranged

Admit Criteria
Unstable clinical status and/or clinical infection
requiring inpatient stay or
Disabling parental anxiety or
Uncertain home situation or
Barriers to safe return to home

Discharge
Admit

Parental
Education
ED Febrile
Seizure discharge
instructions
Follow-up with
primary MD

Phase
Change

For questions concerning this pathway,

contact: [email protected]
2011, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 11/09/2011

Valid until:11/01/2014

Yes

Febrile Seizure v.1.1: Inpatient Management

FebrileSeizure
SeizureAdmit
AdmitOrders
Orders
Febrile

PHASE II:
INPATIENT

Use Febrile Seizure Admit Orderset

RN Teaching: Seizures From a Fever
Seizure Precaution
Order seizure rescue plan (Acute Seizure Management Orderset) if
Complex febrile seizures or
Concern for intracranial infection

If Actively Seizing, Use Acute Seizure Management Orderset

Signs and Symptoms of Meningitis or Intracranial Infection

No

AssessRisk
Riskfor
of Meningitis or Intracranial Infection
Assess
History
>3 days duration of illness
Seen by primary MD in previous 24
hours
Drowsiness or vomiting at home
Infant 6-12 months old deficient in
Hib or pneumococcal vaccines or
immunization status cannot be
determined
Pretreated with antibiotics

Physical Signs
Petechiae
Questionable nuchal rigidity
Drowsiness
Convulsing on examination
Weakness or neurological deficit on
examination
Signs of infection of head or neck with
potential for intracranial extension
(such as mastoiditis, sinusitis, etc.)
Bulging fontanelle

Complex Features
Focal seizures
Seizure duration >15 minutes
Multiple seizures in 24 hours

Yes

Meningitis Less Likely

Prior febrile seizure
Pre-existing neurological
findings

Clinical judgement of
significant risk

Clinical judgement of
low risk

Acute
Acute Evaluation
Evaluation
Lab testing should focus on finding the cause of the patients
fever
Routine analysis of serum electrolytes, calcium, phosphorus,
complete blood count and blood glucose are not
recommended, unless they are indicated by a suspicious
history or physical findings.
If vomiting and/or diarrhea, refer to Acute Gastoenteritis
Gastroenteritis
Pathway
Blood glucose level and urine drug screen may be
considered useful if the child does not return to baseline
mental status or regain consciousness after the seizure.
Consider neurology consultation if new prolonged focal
neurologic deficit with suspicion of subclinical status
epilepticus or seizure duration > 30 minutes
EEG or neuroimaging not recommended for routine
evaluation

Evaluate for Meningitis

or Intracranial Infection

No
meningitis

Consider CT if concern for increased intracranial

pressure
Lumbar Puncture
Labs: CBC, blood culture, glucose
Treat with empiric antibiotics
Meningitis present

Off
Pathway

Consider outpatient f/u

Consider Non-Urgent Outpatient Follow-up

When to consider neuro consult, outpatient EEG, outpatient MRI
Assess discharge criteria

Discharge Criteria
Patient appears non-toxic and returns to
neurological baseline
Parental anxiety addressed
Parental education provided
Appropriate outpatient follow-up is identified
Discharge

Parental Education
Discharge nursing
instructions
Pamphlet
PamphletPE
PE265
265 Febrile
Seizures
Follow-up with primary
MD

For questions concerning this pathway,

contact: [email protected]
2011, Seattle Childrens Hospital, all rights reserved, Medical Disclaimer

Last Updated: 11/09/2011

Valid until:11/01/2014

Inclusion and Exclusion Criteria

Patients who meet the following criteria should be placed on the febrile
seizure pathway through the use of the febrile seizure admit orderset.

Insert
Inclusion Criteria
Picture
Patients age 6-60 months with seizure AND fever
or-38C
or parental report of fever within 24 hours
graphic
Exclusion Criteria
- Known afebrile seizure disorder
- Probable intracranial infection
- Intracranial shunt
- Immunodeficiency
- Cardiac right-to-left shunt
- Oncology patients

Return to ED
Management

Return to Inpatient
Management

Actively Seizing
ED patients:

If Actively Seizing, Use ED Seizure (Status Epilepticus ) Orderset

Inpatients:

If Actively Seizing, Use Acute Seizure Management Orderset

Actively seizing means convulsive seizures or partial seizures with clear ictal motor
activity for longer than 5 minutes. Not shivering, shuddering or tremor due to fever!

Give rescue anti-epileptic drug if seizing for more than 5 minutes. [Expert opinion]
(Shinnar, 2008)

Intranasal midazolam and buccal midazolam are efficacious and safe, and may
serve as first-line in the treatment of prolonged seizures. Both IV midazolam and
valproate are equally effective to IV diazepam. [High quality](Sofou, 2008 )

Consider obtaining bedside blood glucose. [Expert opinion](Baumer, 2004)

Return to ED
Management

Return to Inpatient
Management

Return to ED
Management

Return to Inpatient
Management

Return to ED
Management

Return to Inpatient
Management

Assess Risk of Meningitis or Intracranial Infection

Children with the following HISTORICAL features
have an increased risk of meningitis and lumbar
puncture should be CONSIDERED:
A child with at least three days of illness, seen by GP in
previous 24 hours, with drowsiness at home, or vomiting at
home. [Low quality](Baumer, 2004)

An infant between 6 and 12 months of age who is considered

deficient in Haemophilus influenzae type b (Hib) or
Streptococcus pneumoniae immunizations (i.e., has not
received scheduled immunizations as recommended) or when
immunization status cannot be determined because of an
increased risk of bacterial meningitis. [Expert opinion](AAP,
2011)
A child who is pretreated with antibiotics, because antibiotic
treatment can mask the signs and symptoms of meningitis.
[Expert opinion](AAP, 2011)

Return to ED
Management

Return to Inpatient
Management

Assess Risk of Meningitis or Intracranial Infection

Children with the following PHYSICAL EXAM
features have an increased risk of meningitis
and lumbar puncture should be CONSIDERED:
Children with petechiae, questionable nuchal rigidity,
drowsiness, convulsing on examination, weakness on
examination, bulging fontanel. [Low quality](Baumer, 2004)

Some studies have suggested that abnormal neurological or

mental status examinations are most predictive of meningitis/
intracranial infection: patients are described as obtunded,
comatose, unresponsive, lethargic, drowsy, prolonged postictal state, agitated, combative, irritable, cranky, clingy,
moaning, toxic. [Low quality] (Selz, 2009; Kimia, 2010; Batra,
2011; AAP 2011)
Signs of infection of the head or neck with potential for
intracranial extension (such as mastoiditis, sinusitis, etc.)
[Local expert opinion]
No evidence was found to support the suggestion that
children below a certain age do not exhibit the signs of
meningitis. (Baumer, 2004)

Return to ED
Management

Return to Inpatient
Management

Assess Risk of Meningitis or Intracranial Infection

Children with COMPLEX FEBRILE SEIZURES may
have an increased risk of meningitis and lumbar
puncture should be CONSIDERED
There is some inconsistency in the literature regarding the
approach to patients with complex febrile seizures (CFS).
Two guidelines state that LP should be CONSIDERED in children
with CFS. [Low quality] (Baumer, 2004; Fetveit, 2008) One guideline
RECOMMENDS lumbar puncture for all patients with CFS. [Expert
opinion] (Boyle, 2011) And one guideline makes no distinction
between children with CFS and children with simple febrile
seizures (SFS) when assessing their risk of meningitis/intracranial
infection. [Expert opinion] (BC Guideline, 2011)
The PAERG systematic review looked a 4 studies from 1981 -92,
and found that the historic pooled rate for meningitis following
febrile seizure was 2.9% overall, with a rate of 2% in SFS and 9.1%
in CFS. [Low quality] (PAERG, 2002)
However, recent studies in the age of Hib and Pneumococcal
vaccines have shown the rate of meningitis CFS to be very low at
<1%, [Low quality] (Selz, 2009; Kimia, 2010) and similar to the rate for
SFS. [Low quality] (Trainor, 2001)

Return to ED
Management

Return to Inpatient
Management

Assess Risk of Meningitis or Intracranial Infection

Children with a previous history of febrile

seizures or history of pre-existing neurological
abnormality may be less likely to have meningitis
or intracranial infection associated with
subsequent febrile seizures.
[Local expert opinion]

Return to ED
Management

Return to Inpatient
Management

Evaluate for Meningitis or Intracranial Infection

A lumbar puncture should be performed in any

child with febrile seizure who presents with
DEFINITE signs or symptoms of meningitis/
intracranial infection or who is felt to be at
SIGNIFICANT RISK for meningitis/intracranial
infection.
Consider obtaining head CT prior to lumbar
puncture if there are signs of increased intracranial
pressure or concerns of intracranial mass.
[Local expert opinion]

Blood culture and serum glucose testing should be

performed concurrent to LP to increase the
sensitivity for detecting bacteria and to determine if
there is hypoglycorrhachia characteristic of
bacterial meningitis. [Expert opinion] (AAP, 2011)
Strongly consider starting empiric antibiotics while
awaiting results of lumbar puncture. [Local expert
opinion]

Return to ED
Management

Return to Inpatient
Management

Meningitis Patients are Off-Pathway

Patients with meningitis or intracranial

infection are OFF THE PATHWAY
Further evaluation and treatment should be
based on meningitis guidelines and/or
Infectious Disease recommendations.

Return to ED
Management

Return to Inpatient
Management

Acute Evaluation

Children felt to be at low risk of meningitis, and those with negative

results from lumbar puncture, should undergo evaluation focusing on
finding the cause of their fever. [Low quality] (AAP, 2011; BC, 2010;
Fetveit, 2008)

Lab testing may be indicated based on the patients underlying

condition, or disease-specific guidelines (e.g., lytes for patient with
known diabetes insipidus). [Local expert opinion]

Children with febrile seizures are at similar risk for occult bacteremia
as those with fever alone. [Low quality] (Trainor, 2001; Shah, 2002)

Consider obtaining blood glucose level [Expert opinion] (Baumer, 2004;

Fetveit, 2008) and urine drug screen [Local expert opinion] if child does
not return to baseline mental status.

Return to ED
Management

Return to Inpatient
Management

Acute Evaluation

Emergent /urgent EEG and neurology consult may have a limited role in
the diagnosis of acute status epilepticus. These patients may present
with very prolonged neurological deficits / encephalopathy following a
febrile seizure, or with very prolonged seizures. [Very low quality] (Shinnar,
2008; Maytal, 2000); [Expert opinion] (BC, 2010; Boyle, 2011)
In one multicenter prospective study, one third of febrile status
epilepticus was not recognized in the emergency department. [Low
quality] (Shinnar, 2008)

Acute Evaluation

Emergent/urgent neuroimaging is unnecessary for well-appearing

children. [Very low quality] (AAP, 2011; Boyl, 2011; Millichap, 2008;
Hesdorffer, 2008; Teng, 2006; Maytal, 2000; Yucel, 2004)

Consider emergent/urgent CT for children with:

New prolonged focal neurological deficits
Patients who are obtunded
First complex febrile seizure AND one of the following:
Concern for increased intracranial pressure
Concern for localized intracranial infection
Concern for intracranial mass
Trauma
[Local expert opinion]

Return to ED
Management

Return to Inpatient
Management

Planning Outpatient Follow-up: Neurology Consultation,

Outpatient EEG, or MRI

Not recommended for simple febrile seizure. [Low quality] (AAP, 2011)

Consider non-urgent outpatient neurology consultation, EEG, and

MRI for patients with complex febrile seizure AND other risk factors
for epilepsy: [Local expert opinion]

Family history of epilepsy

Previous traumatic brain injury or central nervous system infection
Previous or current episode(s) of status epilepticus (seizure duration >30 minutes)
Baseline neurodevelopmental or neurological deficits/abnormalities (cerebral palsy,
developmental delay, macro/microcephaly)
Evidence of neurocutaneous syndrome (neurofibromatosis, tuberous sclerosis, etc)

Planning Outpatient Follow-up: Outpatient EEG

EEGs are not typically indicated following a first episode single

simple or complex febrile seizure. [Low quality] (AAP, 2011; Maytal,
2000)

Providers may consider obtaining an EEG at least 7 days after a

single complex febrile seizure if the child has other risk factors for
epilepsy. [Very low quality] (Joshi, 2005; Boyle, 2011)

However, an abnormal EEG following a single simple or complex

febrile seizure is unlikely to change management. [Very low quality]
(Maytal, 2000; Joshi, 2005)

To Non-Urgent
Follow up Pg2

Return to ED
Management

Return to Inpatient
Management

Planning Outpatient Follow-up: Outpatient MRI

Neuroimaging is not typically indicated following a first episode single

simple or complex febrile seizure. [Very low quality] (AAP,2011; Boyle,
2011; Hesdorffer, 2008; Teng, 2006; Yucel, 2004)

If neuroimaging is done, MRI is more sensitive than CT. [Expert opinion]

(Boyle, 2011; BC, 2010; Prince, 2009)

Providers may consider obtaining a non-urgent MRI for:

recurrent complex febrile seizures. [Expert opinion] (BC, 2010)
a single complex febrile seizure if the child has other risk factors
for epilepsy. [Expert opinion] (BC, 2010; Boyle, 2011)

Return to ED
Management

Return to Inpatient
Management

Criteria for Inpatient Admission

Children who are clinically unstable neurologically (e.g., not returning to baseline, very somnolent

following doses of anti-seizure medications) should be admitted for observation and support. [Expert
opinion] (Fetveit, 2008; Baumer, 2004)
Children who present with an underlying infection requiring inpatient stay (e.g., severe pneumonia,
infection requiring intravenous antibiotics) should be admitted. [Expert opinion] (BC, 2010)
Children whose parents have "disabling" anxiety following the seizure episode may require
admission for observation and further parental education and reassurance. [Expert opinion] (BC,
2010; Fetveit, 2008)

Children that lack a safe home or safe transportation home require admission and may require
social work consultation. [Expert opinion] (Fetveit, 2008)

Return to ED
Management

Return to Inpatient
Management

Inpatient Admission
Febrile Seizure Admit Orders
Use Febrile Seizure Admit Orderset
RN Teaching: Seizures From a Fever
Seizure Precaution
Order seizure rescue plan (Acute Seizure Management Orderset) if
Complex febrile seizures or
Concern for intracranial infection
Use the "Febrile Seizure Admit Orderset". The orderset helps ensure that key
items such as parental education and seizure precautions are considered, and
allows for tracking of febrile seizure patients for outcomes measures.
Patients admitted following a single simple febrile seizure do not require a seizure
rescue plan. A seizure rescue plan should be ordered (using the "Acute Seizure
Management Orderset") for patients with complex febrile seizures. [Local expert
opinion]

Return to ED
Management

Return to Inpatient
Management

Discharge Criteria
ED patients

Inpatients

ED Discharge Criteria
Cause of fever does not require inpatient admission
Patient appears non-toxic and returns to
neurological baseline
If complex febrile seizure: observe 2 hours after
seizure
Parental anxiety addressed
Parental education provided
Appropriate outpatient follow-up is identified
Safe transport home arranged

or

Discharge Criteria
Patient appears non-toxic and returns to
neurological baseline
Parental anxiety addressed
Parental education provided
Appropriate outpatient follow-up is identified

Children who appear non-toxic and are at their neurologic baseline following a febrile
seizure may be safely discharged home. [Expert opinion] (Baumer, 2004; BC, 2011)
Children who present with a complex febrile seizure should be observed for a minimum
of 2 hours, and then may be discharged home if they appear non-toxic and have
returned to their neurological baseline. [Expert opinion] (Baumer, 2004)
Addressing parental anxiety and providing parental education are often the key tasks of
the medical team following a febrile seizure. [Expert opinion] (Baumer, 2004; BC, 2010;
Boyle, 2011)

Return to ED
Management

Return to Inpatient
Management

Discharge from the Emergency Department

The vast majority of febrile seizure patients can

be directly discharged home from the ED.
Upon discharge from the emergency
department, the child's caregiver should be
provided with:
The ED Febrile Seizure discharge instructions.
Plan to follow-up with the child's primary care
provider.

Return to ED
Management

Return to Inpatient
Management

Discharge from the Hospital

A small number of patients will require inpatient

admission.
Upon discharge from the hospital, the child's
caregiver should be provided with:

Parental Education

Discharge Nursing Instructions.

Parent education sheet about Seizures from a Fever
(#PE265).

Discharge nursing
instructions
Pamphlet PE265 Febrile
Seizures
Follow-up with primary
MD

Plan to follow-up with the child's primary care

provider.

Return to ED
Management

Return to Inpatient
Management

To Pg 2

Return to ED
Management

Back

Return to ED
Management

Self-Assessment
Completion qualifies you for 1 hour of Category II CME credit. If you are taking this self-assessment as a
part of required departmental training at Seattle Childrens Hospital, you MUST logon to Learning Center.
1.

Which of the following is NOT an exclusion criterion for being on the SCH Febrile Seizure Pathway?
a.
Known epilepsy
b.
Meningitis
c.
Cerebral palsy
d.
Immunodeficiency

2.

For the patient that is actively seizing, anti-seizure drugs should be administered after:
a.
2 minutes
b.
5 minutes
c.
10 minutes
d.
15 minutes

3.

When assessing a child with febrile seizures, which of the following historical features is NOT associated with an increased
risk of meningitis?
a.
Greater than 3 days of illness
b.
History of prior febrile seizure
c.
6-12 months of age with incomplete immunizations to Hib and pneumococcus
d.
Pretreated with antibiotics

4.

Which of the following is a feature of a complex febrile seizure?

a.
Focal seizures
b.
Seizure lasting more than 15 minutes
c.
Multiple seizures in 24 hours
d.
All of the above

5.

Which of the following statements is NOT true about the acute evaluation of febrile seizures?
a.
Routine lab testing, EEG, and neuroimaging are generally not indicated in well-appearing children following a
febrile seizure.
b.
Limited lab testing should focus on finding the cause of the patients fever.
c.
Children with febrile seizures are at an increased risk for occult bacteremia compared to children with fever alone.
d.
Blood glucose level and urine drug screen may be considered in the child that does not return to baseline mental
status following a febrile seizure.

6.

Emergent/urgent EEG may be indicated in the emergency department during evaluation for a febrile seizure when:
a.
There is concern for increased intracranial pressure
b.
There is concern that the patient may develop epilepsy in the future
c.
There is a family history of febrile seizures
d.
There is concern that the patient is in status epilepticus

7.

Following a simple febrile seizure, one of the key tasks at the time of discharge is to:
a.
Address parental anxiety and provide parental education.
b.
Provide instructions for round-the-clock acetaminophen administration with the next febrile illness to prevent
further seizures.
c.
Arrange outpatient EEG and neurology follow-up.
d.
Arrange for MRI in 7 14 days.

8.

Which of the following does NOT meet criteria for inpatient admission following a febrile seizure?
a.
The child that remains very somnolent following 2 doses of anti-seizure medications given in the ED.
b.
The child with parents who state they were scared to death by the seizure, and despite reassurance in the ED,
are refusing to take him home until theyre sure he wont seize again.
c.
The child with pneumonia and effusion, with a room air oxygen saturation of 86%.
d.
All patients with complex febrile seizures.

9.

Non-urgent outpatient neurology consultation, EEG and MRI following a febrile seizure would be most appropriate for:
a.
Patients following a simple febrile seizure
b.
Patients following a complex febrile seizure
c.
Patients with complex febrile seizures and other risk factors for epilepsy
d.
Patients who underwent lumbar puncture as part of their evaluation

10.

Children that present with a complex febrile seizure should be observed for a minimum of 2 hours, and then may be
discharged home if they appear non-toxic and have returned to their neurological baseline.
a.
True
b.
False
Return to ED

Management

View Answers

Answer Key
1.

c.
Pre-existing neurological conditions, such as cerebral palsy, are NOT exclusion criteria for the febrile seizure
pathway at SCH. The other listed conditions are exclusion criteria for the pathway.

2.

b.
Recent studies suggest that anti-seizure drugs should be administered when the seizure duration exceeds 5
minutes.

3.

b.
Children who present with a febrile seizure and have a previous history of febrile seizures or history of preexisting neurological abnormality may have a decreased risk of meningitis or intracranial infection.

4.

d.

5.

c.
Children with febrile seizures are at similar risk for occult bacteremia as those with fever alone. Choices a,
b, and d are key recommendations regarding the acute evaluation of a febrile seizure.

6.

d.
Although emergent/urgent EEG is rarely indicated for febrile seizures, a STAT EEG should be considered
when there is concern that a patient is in status epilepticus.

7.

a.
Addressing parental anxiety and providing parental education are key tasks for the medical team at the time
of discharge. Antipyretics do NOT prevent febrile seizures. EEG and MRI are generally not indicated
following a simple febrile seizure.

8.

d.
Most patients with complex febrile seizures can be safely sent home after being observed for 2 hours. The
patient in (a) is unstable neurologically and should be admitted. The parents in (b) appear to have
"disabling" anxiety following the seizure episode and require admission for observation and further parental
education and reassurance. The patient in (c) has an underlying infection requiring inpatient stay
(pneumonia with hypoxia).

9.

c.
Non-urgent outpatient neurology consultation, EEG and MRI following a febrile seizure would be most
appropriate for a patient with complex febrile seizure AND other risk factors for epilepsy. Risk factors for
epilepsy include: family history of epilepsy, previous traumatic brain injury or central nervous system
infection, previous or current episode(s) of status epilepticus (seizure duration >30 minutes), baseline
neurodevelopmental or neurological deficits/abnormalities (cerebral palsy, developmental delay, macro/
microcephaly), and evidence of neurocutaneous syndrome (neurofibromatosis, tuberous sclerosis, etc).
Non-urgent outpatient neurology consultation, EEG and MRI are not indicated for simple febrile seizures and
most complex febrile seizures. Non-urgent outpatient neurology consultation, EEG and MRI are not
indicated for most patients with negative lumbar puncture results.

10.

a.

Return to ED
Management

Evidence Ratings
We used the GRADE method of rating evidence quality. Evidence is first assessed as to
whether it is from randomized trial, or observational studies. The rating is then adjusted in
the following manner:
Quality ratings are downgraded if studies:
Have serious limitations
Have inconsistent results
If evidence does not directly address clinical questions
If estimates are imprecise OR
If it is felt that there is substantial publication bias
Quality ratings can be upgraded if it is felt that:
The effect size is large
If studies are designed in a way that confounding would likely underreport the magnitude
of the effect OR
If a dose-response gradient is evident
Quality of Evidence:
High quality
Moderate quality
Low quality
Very low quality
Expert Opinion (E)
Reference: Guyatt G et al. J Clin Epi 2011: 383-394

Return to ED
Management

To Bibliography

Summary of Version Changes

Version 1 (11/15/2011): Go live

Return to ED
Management

Disclaimer
Medicine is an ever-changing science. As new research and clinical experience
broaden our knowledge, changes in treatment and drug therapy are required.
The authors have checked with sources believed to be reliable in their efforts to
provide information that is complete and generally in accord with the standards
accepted at the time of publication.
However, in view of the possibility of human error or changes in medical sciences,
neither the authors nor Seattle Childrens Healthcare System nor any other party
who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or for the results obtained
from the use of such information.
Readers should confirm the information contained herein with other sources and
are encouraged to consult with their health care provider before making any
health care decision.
Return to Home

Bibliography

Identification
128 records identified through
database searching

4 additional records identified

through other sources

Screening
130 records after duplicates removed

130 records screened

78 records excluded

52 full-text articles assessed for eligibility

29 full-text articles excluded,

15 did not answer clinical question
14 did not meet quality threshold

Elgibility

Included
23 articles included in pathway
Flow diagram adapted from Moher D et al. BMJ 2009;339:bmj.b2535

To Pg 1

Return to ED
Management

Bibliography
Guidelines and Reviews
(AAP), Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child
with a simple febrile seizure. Pediatrics [IBD]. 2011;127(2):389-394.
Baumer, JH. (2004). Evidence based guideline for post-seizure management in children presenting acutely to
secondary care. Arch Dis Child; 89:278-280.
(BC), Febrile seizures. (2010). Clinical Practice Guidelines and Protocols in British Columbia
Boyle, G., & Dynamed Editorial Team. (2011). Febrile seizure., 6/6/2011, from
http://search.ebscohost.com/login.aspx?direct=true&site=dynamed&id=AN+113623

Fetveit, A. (2008). Assessment of febrile seizures in children. European Journal of Pediatrics, 167(1), 17-27.
(PAERG), Paediatric Accident and Emergency Research Group. (2002). Evidence based guideline for post seizure
management.

To Pg 2

Return to ED
Management

Bibliography
Articles
Batra, P., Gupta, S., Gomber, S., & Saha, A. (2011). Predictors of meningitis in children presenting with f irst f ebrile seizures. Pediatric
Neurology, 44(1), 35-39.
Cuestas, E. (2004). Is routine EEG helpf ul in the management of complex f ebrile seizures? Archives of Disease in Childhood, 89(3), 290.
Hesdorf f er, D. C., Chan, S., Tian, H., Allen Hauser, W., Dayan, P., Leary, L. D., et al. (2008). Are MRI-detected brain abnormalities
associated with f ebrile seizure type?. Epilepsia, 49(5), 765-771.
Joshi, C., Wawrykow, T., Patrick, J., & Prasad, A. (2005). Do clinical variables predict an abnormal EEG in patients with complex f ebrile
seizures?. Seizure, 14(6), 429-434.
Kimia, A., Ben-Joseph, E. P., Rudloe, T., Capraro, A., Sarco, D., Hummel, D., et al. (2010). Yield of lumbar puncture among children who
present with their f irst complex f ebrile seizure. Pediatrics, 126(1), 62-69.
Maytal, J., Krauss, J. M., Novak, G., Nagelberg, J., & Patel, M. (2000). The role of brain computed tomography in evaluating children with
new onset of seizures in the emergency department. Epilepsia, 41(8), 950-954.

Maytal, J., Steele, R., Eviatar, L., & Novak, G. (2000). The value of early postictal EEG in children with complex f ebrile seizures.
Epilepsia, 41(2), 219-221.
Millichap JJ, Gordon Millichap J. Methods of investigation and management of inf ections causing f ebrile seizures. Pediatr Neurol.
2008;39(6):381-386.
Prince JS, Gunderman R, Coley BD, Bulas D, Holloway K, Karmazyn B, Meyer JS, Paidas C, Podberesky DJ, Ragheb J, Rodriguez W,
Rosenow JM. ACR appropriateness criteria seizures child. 2009. Accessed 6/3/2011.

To Pg 3

Return to ED
Management

Bibliography
Saltik, S., Angay, A., Ozkara, C., Demirbilek, V., & Dervant, A. (2003). A retrospective analysis of patients with
febrile seizures followed by epilepsy. Seizure, 12(4), 211-216.
Seltz LB, Cohen E, Weinstein M. Risk of bacterial or herpes simplex virus meningitis/encephalitis in children with
complex febrile seizures. Pediatr Emerg Care. 2009;25(8):494-497.
Shah S, Alpern E, Zwerling L, Reid J, et al. Low risk of bacteremia in children with febrile seizures. Arch Pediatr
Adolesc Med. 2002;156:469-472.
Shinnar S, Hesdorffer DC, Nordli DR,Jr, et al. Phenomenology of prolonged febrile seizures: Results of the
FEBSTAT study. Neurology [IBD]. 2008;71(3):170-176.
Sofou K, Kristhansdottir R, Papachatzakis N, et al. Management of prolonged seizures and status epilepticus in
childhood: a systematic review. Journal of Child Neurology. 2009; 24(8), 918-926.

Teng D, Dayan P, Tyler S, et al. Risk of intracranial pathologic conditions requiring emergency intervention after a
first complex febrile seizure episode among children. Pediatrics. 2006;117(2):304-308.
Trainor J, Hampers L, Krug S, Listernick R. Children with first-time simple febrile seizures are at low risk of serious
bacterial illness. Academic Emergency Medicine. 2001; 8(8), 781-787.
Yucel O, Aka S, Yazicioglu L, Ceran O. Role of early EEG and neuroimaging in determination of prognosis in
children with complex febrile seizure. Pediatrics International. 2004;46(4):463-467.

Return to ED
Management