Scenario 2

Emily is given two doses of IV - midazolam 0.15mg/kg followed by phenytoin 20mg/kg over 20 minutes. Her seizures cease after the phenytoin has been running for 10 minutes.

She is also commenced on IV antibiotics (IV cefotaxime) as she is unable to be assessed properly neurologically. Emily has routine bloods including FBC, UEC, glucose and blood cultures performed. Her WCC is 16 but investigations are otherwise normal.

A UA is normal apart from trace ketones. She wakes up within an hour of her seizure and has no signs of neck stiffness or photophobia.

Further examination reveals no rashes. Her vital signs normalise once her temperature settles.

She has mild rhinorrhoea and a red throat. Her chest is clear and her heart sounds are dual with no murmur.

Question 06

What is the most likely cause of Emily’s seizure? Which one of the following is the best answer:
Urinary tract infection
Encephalitis
Viral infection
Meningitis
Strep tococcal pharyngitis
Check answer

Explanation

By far the most likely cause of febrile convulsions is a non-specific viral illness. In simple febrile convulsions where the focus of infection can be identified, blood tests and invasive investigations are often not indicated. A lumbar puncture should be considered if:

  • the child is under 12 months and not up to date with immunisations
  • they are clinically unwell
  • they are already on oral antibiotics which may mask meningitis.

Question 07

What needs to occur before Emily can be discharged? Choose one of the answer options below, made up of three items from the following list:

A) MRI brain
B) EEG
C) Return to normal neurological state
D) Serious bacterial infection excluded or adequately treated
E) Parental education regarding febrile convulsions

A, D, E
C, D, E
A, B, C
C, B, D
B, D, E
Check answer

Explanation

An EEG and MRI is not indicated in the case of a simple febrile convulsion. Given that Emily has had an initial focal component to her seizure, most clinicians would perform an EEG as an outpatient as she is at risk of a focal epileptiform focus. There is debate as to whether this is indicated as most clinicians would not commence antiepileptiform treatment following a single febrile seizure.

Depending on the EEG result and subsequent progress, Emily may or may not proceed to an MRI brain. In the child who has an acute neurological deficit after the seizure or who remains encephalopathic, imaging would be indicated to exclude focal neurology such as a stroke. In the first instance, this would generally be a CT brain.

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