EDs not complying with pediatric seizure guidelines

Invasive work-ups are discouraged

ED Nursing
Copyright 2007 Gale Group, Inc.
All Rights Reserved
ASAP
Copyright 2007 A Thomson Healthcare Company

A decade after the American Academy of Pediatrics (AAP) published its guidelines for the acute management of febrile seizure, ED staff still are giving children head CT scans, which aren’t recommended forthese patients, says a new study.¹

The AAP guidelines for febrile seizure discourage aggressive neurodiagnostic testing.² The researchers reviewed records of 1,029 children between 6 months and 6 years of age diagnosed with febrile seizureat 42 community EDs. They found that although lumbar punctures were done in only 5.2% of cases, head CT scans were done in 11% of cases.

The relatively frequent use of head CT scans is inconsistent with current recommendations, says Louis Hampers, MD, the study’s lead author and ED physician at the Children’s Hospital in Denver. “The AAP guidelines emphasize the very benign nature of febrile seizures and discourage invasive work-ups,” he says. Children who have had a febrileseizure are at no greater risk for serious bacterial illness than febrile children of the same age group who have not had a seizure, he adds.

“It is often difficult to recognize this parallel, as most kids who’ve had a febrile seizure come emergently to the ED by EMS, with appropriately ‘freaked-out’ parents,” says Hampers. “But, really the approach to these kids shouldn’t be any different than for the febrile toddler waiting quietly in triage.”

Take these steps in your ED

The majority of children with febrile seizures arrive at an ED viaambulance, says Cheryl Stiles, RN, Clinical Director for the ED at The Children’s Hospital in Denver. “This is not something that most parents have ever dealt with—and it is a very scary thing to see your child have a seizure, so they usually call 911,” she explains. “At the time of arrival, most children are not actively seizing.”

During the initial assessment of a child presenting with a historyof febrile seizure, these steps occur:

• The airway is assessed for patency, and the child is suctioned ifneeded. “The first thing we think is, ‘Is the airway compromised?’” says Stiles. “Sometimes children will present with a lot of secretions and they need to be suctioned, or you may just need to reposition their head.”
• Breathing is assessed next. “If a child is actively seizing when they arrive in the ED, we place them on oxygen,” says Stiles. All emergency equipment is kept at the bedside, including an anesthesia bag and mask connected to the oxygen source and equipment to suction — so if the child seizes again, the supplies are at the nurses’ fingertips.
• Next, the circulatory status is quickly assessed and the child isplaced on a cardiac monitor.
• Blankets or padding may be placed on the side rails to protect the child from injury that might occur during a seizure.
• Nurses continue to monitor the child’s airway, breathing and circulation.

Most children don’t have another febrile seizure while in the ED and are discharged to their home, says Stiles. “If there is an obvioussource that caused the fever that led to the seizure, then we treat the cause of the infection if possible,” she says.

Always take the opportunity to educate parents, says Stiles. “There is a misconception that if you have a really high temperature or a febrile seizure that brain damage might occur,” she says. Also, explain to parents that it is not so much the height of the temperature asthe speed at which the temperature increases, so you can have a febrile seizure with a temperature of 102 deg. Stiles explains. “Always comfort and reassure the parents, as they are appropriately frightened,” she says.

Explain the importance of giving an appropriate dose of an antipyretic for the child’s weight, so they can keep their temperature down and potentially avoid another seizure, says Stiles.

When obtaining the history, ask whether the child has been sick, what their complaints were prior to the seizure, and whether there is a family history of seizures, says Stiles. “Ask whether the child hasbeen exposed to contagious illnesses like chicken pox or strep,” shesays. “The answers to these questions can often help the provider.”

References

1. Hampers LC, Thompson DA, Bajaj L, et al. Febrile seizure: Measuring adherence to AAP guidelines among community ED physicians. Ped Emerg Care 2006; 22:465-469.
2. American Academy of Pediatrics, Provisional Committee on Quality Improvement, Subcommittee on Febrile Seizures. Practice parameter: The neurodiagnostic evaluation of the child with a first simple febrileseizure. Pediatrics 1996; 97:769-772.

Sources

For more information on diagnostic testing for pediatric febrile seizures, contact:

• Louis Hampers, MD, Emergency Department, The Children’s Hospital,1056 E. 19th Ave., Denver, CO 80218. Phone: (303) 837-2868.
• Cheryl Stiles, RN, Director of Nursing, Emergency Department, TheChildren’s Hospital, 1056 E. 19th Ave., Denver, CO 80218. Phone: (303) 864-5614.