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Faizunnur Erfin 0606103874 Resource Person Dr. Amril Amirman Burhany, Sp.A(K)
Faculty of Medicine, Universitas Indonesia Departemen Ilmu Kesehatan Anak Jakarta
1 Febrile convulsions. but are referred to as seizures with fever. Febrile seizures are age dependent and are rare before 9 mo and after 5 yr of age. especially when it is the 1st seizure. The risk of epilepsy is much higher than in the general population in children with one or more complex febrile seizures. An autosomal dominant inheritance pattern is demonstrated in some families. especially if the seizures are focal in children with an 1 . and occurs only once in 24 hr. Factors associated with increased recurrence risk include age <12 mo. Some children have a chronic seizure disorder with more seizures during fever. and most children with febrile seizures have only a slightly greater risk of later epilepsy than the general population. The peak age of onset is ≈14–18 mo of age. and this manifests itself as loss of consciousness and abnormal movements. or when focal seizure activity or focal findings are present during the postictal period. or a pre-existing neurologic disorder. A simple febrile convulsion is usually associated with a core temperature that increases rapidly to ≥39°C. and the incidence approaches 3–4% of young children. a positive family history of epilepsy. Factors that are associated with a substantially greater risk of later epilepsy include the presence of complex features during the seizure or postictal period. In a generalized convulsion all four limbas and the face are affected. lower temperature before seizure onset. each child with a seizure associated with fever must be carefully examined and appropriately investigated for the cause of the fever. Convulsionn are due to synchronous discharge of electrical activity from a number of neurones. generally have an excellent prognosis but may also signify a serious underlying acute infectious disease such as sepsis or bacterial meningitis. the most common seizure disorder during childhood. is followed by a brief postictal period of drowsiness. when repeated convulsions occur within 24 hr. lasts a few seconds and rarely up to 15 min. Febrile seizures are not associated with reduction in later intellectual performance.Chapter 1: Literature Review Complex febrile convulsion Background Generalized convulsionss The term convulsion is synonymous with fit or seizure. A febrile seizure is described as complex or complicated when the duration is >15 min. These are not febrile seizures. A strong family history of febrile convulsions in siblings and parents suggests a genetic predisposition. and complex features. Convulsive status epilepticus (one seizure lasting 30 min or multiple seizures during 30 min without regaining consciousness) is often due to central nervous system infection (viral or bacterial meningitis). Linkage studies in several large families have mapped the febrile seizure gene to chromosomes 19p and 8q13–21.2 CLINICAL MANIFESTATIONS. Approximately 30–50% of children have recurrent seizures with later episodes of fever and a small minority has numerous recurrent febrile seizures. It is initially generalized and tonic-clonic in nature. an initial febrile seizure before 12 mo of age. a positive family history of febrile seizures. delayed developmental milestones. Therefore.
but symptoms of lethargy. A lumbar puncture should be strongly considered in children <12 mo of age and considered in those 12–18 mo of age. but the potential risks of the drug do not justify its use in a disorder with an excellent prognosis regardless of treatment. Phenobarbital prevents recurrent febrile seizures but may also decrease cognitive function in treated children compared with untreated children. Similarly. 0. is administered for the duration of the illness (usually 2–3 days). especially that caused by herpes simplex. If parental anxiety is very high. At the onset of each febrile illness. Preventive anticonvulsant treatment 2 . The incidence of fatal valproate-induced hepatotoxicity is highest in children <2 yr of age. oral diazepam. laboratory testing such as serum electrolytes and toxicology screening should be ordered based on individual clinical circumstances such as evidence of dehydration. In a setting where support for ventilation can be provided. including the use of antipyretics. Routine management of a normal infant with simple brief febrile convulsions includes a careful search for the cause of the fever and reassurance and education of the parents. may reduce discomfort and are reassuring. active measures to control the fever. compared with an incidence of 1% in children who have febrile convulsions and no risk factors.2 During the acute evaluation. This will usually terminate the seizure and prevent recurrence over 12 hr. If any doubt exists about the possibility of meningitis.3 mg/kg q8h (1 mg/kg/24 hr). consideration should be given to treating seizures lasting >5 min with a benzodiazepine as a first-line therapy as described in Chapter 593. and acute otitis media are most frequently the causes of febrile convulsions. but may be considered for children with atypical features.8 . a physician's most important responsibility is to determine the cause of the fever and to rule out meningitis or encephalitis. Viral infections of the upper respiratory tract. An electroencephalogram (EEG) is not warranted after a simple febrile seizure but may be useful for evaluating patients with complex or atypical features or with other risk factors for later epilepsy.underlying neurologic disorder. Another approach for selected patients with recurrent complex febrile seizures is to prescribe diazepam in the form of a gel that can be given rectally at the time of a seizure in a dose of approximately 0. a lumbar puncture with examination of the cerebrospinal fluid (CSF) is indicated. The possibility of viral meningoencephalitis should also be kept in mind. neuroimaging is also not useful for children with simple febrile convulsions. including focal neurologic signs or pre-existing neurologic deficits. Antiepileptics such as phenytoin and carbamazepine do not prevent febrile seizures. and ataxia may be reduced by adjusting the dose. Sodium valproate is also effective for prevention of febrile seizures.5 mg/kg for children aged 2–5 yr.2 Seizure-induced CSF abnormalities are rare in children and all patients with abnormal CSF after a seizure should be thoroughly evaluated for causes other than seizure. especially if seizures are complex or sensorium remains clouded after a short postictal period. The side effects are usually minor. Prolonged anticonvulsant prophylaxis for preventing recurrent febrile convulsions is controversial and no longer recommended for most children. irritability. oral diazepam may be used as an effective and safe method of reducing the risk of recurrence of febrile seizures.2 TREATMENT. The incidence of epilepsy is >9% when several risk factors are present. Aside from glucose determination. roseola (and nonroseola human herpes virus 6 and 7 infections). Although antipyretics have not been shown to prevent seizure recurrences.
The risk of multiple recurrences is greater in infants with onset in the first year.2 The prognosis of children with simple febrile seizures is excellent.3 3 . The risk of epilepsy in most children with febrile seizures is no greater than the general population (approximately 1%). Many children have further febrile seizures. family history of epilepsy. The probability of developing epilepsy is 2% if one risk factor is present and 10% if two or three risk factors are present. Intellectual achievements are normal. Factors that increase the risk for the development of epilepsy include abnormal neurologic examination or development. but the development of epilepsy (afebrile seizures) is rare. Febrile seizures recur in 50% of children who have their first febrile seizure at younger than 1 year of age and in 28% of children who have their first seizure at older than 1 year of age. and complex febrile seizures. Children with complex febrile seizures have only a 7% risk of having further complicated febrile seizures.or treatment after the seizure has not been shown to reduce the risk of later epilepsy in higher risk patients. About 10% of children with febrile seizures have three or more recurrences.
30 am) : 79 75 85 : Jamkesmas PARENT’S IDENTITY Father Name Age Education Occupation Religion Suku Mr. Payment method : Child Nayla : Girl : Jl. Jakarta Barat : 16 months old : Betawi : Islam : 4th October 2010 (2. 14 Kebon Jeruk. Musyawaroh No. E 32 years old Junior high graduate House wife Islam Javanese 4 . A 35 years old High school graduate Entepreneur Islam Javanese Mother Mrs.Chapter II Case Illustration PATIENT’S IDENTITIY Name Sex Address Age Ethnicity Religion Date of admission Medical record no.
2.5000.Income Rp.000.-/month None Parent-child relationship: biologic child 5 .
and her mother gave her a sanmol syrup. patient got seizure once. Duration of seizure about 10 minutes and after had a seizure the child cry spontaneusly. History of Present Illness 12 hours before admission. duration 5 minutes. The child was conscious. fever was appears and then the patient had a seizure again. the child suddenly had a fever. the seizure was same like this time (with fever) and got paracetamol to reduce fever. no icteric. Chief Complaint Seizure 30 minutes before hospital admission.with a same type tonic clonic. Spontaneous birth. There is no diarrhea and vomit. History of Pregnancy Patient mother was healthy throughout her pregnancy. and she had a yellow sputum. but about 2 hours later the fever was occur again. History of Family Illness Mother had diagnosed with febrile convulsion when she was child. History of Past Illness At 8 months old. There is no serumen and liquid appears from ear. and the her mother bring her to the emergency RSAB Harapan Kita. But the mother is still panic.ANAMNESIS The information from anamenesis was based on alloanamnesis to the mother and father on 4th October 2010. duration of seizure about 5 minutes and but after had a seizure the child was unconscious. 4 hours before admission. A fever was subsided. fever was appears and then the patient had a seizure again. 30 minutes before admission. no cyanosis. and got a dumin for her child. The child had a cough too. and she go to the clinic near her house. Antenatal visit was irregular. type of seizure is tonic clonic.with a same type tonic clonic. information from RSAB Harapan Kita. duration of seizure about 3 minutes and after had a seizure the child cry spontaneusly. spontaneously cried. 6 . her mother realize that the patient was being seizure. 7 hours before admission.
and cried spontaneously. since 10 months ago patient also drinks formula milk. patient started to eat rice with vegetables on the side. and Puberty Rolling over: at 5 months old. 7 . Birth weight was 3100 gram and birth lenght is 48 cm. Development. Bubur susu at 5 months old. History of Maternal Reproduction Patient is the second child in the family. At 1 year old. yellow or blue.History of Delivery Patient was born with midwife’s help. History of Growth. normal. History of Immunization Patient completed the basic immunization program. Sitting down: at 8 months old Crawling: at eight months old Standing up: at 12 months old Walking: (-). The age of the mother was 21 when she was pregnant. at term. There were no pale. History of Feeding Patient had breastfed until 3 months ago. She started to eat fruits at the age of 2 months old. birth spontaneously. Additionally.
septum deviation (-) Throat: uvula at the middle.PHYSICAL EXAMINATION (Monday. oral thrush (-).9 x 100% = 73.o Clinical interpretation: mild to moderate malnutrition Head circumference: 44 cm (normocephalic) Upper arm circumference: 14 cm General Status Head: deformity (-). tonsil T2/T2. sunken eyes -/Nose: secret -/-. lymph nodes enlargements (-) 8 . icteric sclera -/-. z-score between -1 and -2 SD Height age 9 m. regular.8 % BW/BH = 8/10. PND (-) Teeth and mouth: cyanosis (-). regular. October 4th 2010) General Condition Compos mentis. hair could not easily pulled Eyes: anemic conjuctiva -/-. : 39. sinus pain (-) Hair: hair distribution are equal. good hygiene. hyperemic (+). Irritable Vital Sign Blood Pressure: 100/70 mmHg HR RR : 136 x/minute. carries dentis (-) Neck: trachea in the middle. fontanel closed.4%. edema (-).5% BH/A = 71/79 x 100% = 89. adequate.6 x 100% = 75.1oC axilla Anthropometric Data Body Weight Body Height Nutritional Status : 8 kg : 71 cm : BW/A = 8/10. equal : 36 x/minute. abdominotorakal Temp.
000 ui MCV: . vesicular +/+.intestinal sound (+) normal 1 x/ 5 seconds. rales -/-. wheezing -/Abdomen: supple.8 g/dL Ht: 33 vol% Leu: 6. symmetric expansion.pg MCHC: % 9 .000 ui Glucose test 136 mg/dl Electrolyte (6th October 2010) Complete blood Hb: 10. LABORATORY EXAMINATION (3rd October 2010) Complete blood Hb: 10. right fremitus = left fremitus.pg MCHC: % MCV: . no retraction Heart: ictus cordis is palpated in 5th ICS of left midclavicle line. gallop (-) Lung: symmetric on static and dynamic. liver and spleen were impalpable.CU microns MCH: .CU microns MCH: .500/uL Diff count: -/-/-/77/20/3 % Thrombocyte: 159. balotement -/. pain on palpation (-).CU microns MCH: . CVA pain -/. CRT <2 second. sonor/sonor. murmur (-).Chest: symmetric on static and dynamic.500/uL Diff count: -/-/-/31/63/6 % Thrombocyte: 123. flat.pg MCHC: % (7th October 2010) Complete blood Hb: 11 g/dL Ht: 34 vol% Leu: . 1st and 2nd heart sound are normal.uL Diff count: Thrombocyte: 95. good turgor Extremity: warm extremity.7 g/dL Ht: 33 vol% Leu: 10.000 ui MCV: .
. There were high fever. 3 times in 24 hours.Summary Child. WORKING DIAGNOSIS 1.a girl 16 months old. The patient was diagnosed with complex febrile convulsion and mild moderate malnutrition. cough. Complex febrile convulsion 2.8 mg oral Monitoring vital sign Diet 10.9 x 100 = 1100 kcal/24 hours 10 . unconscious when she had a convulsion. From physical examination her temperature is 39°c. Mild to moderate malnutrition MANAGEMENT Lumbar Puncture Glucose test Electrolyte analysis Dumin (paracetamol) supp 120 mg KAEN 1B 960 mL/24 hours 10 dpm Diazepam 10 mg supp per rectal Diazepam 3 x 0. From laboratory examination got trombositopeni. the type is tonic clonic and after had a convulsion. she was conscious. Wasting and baggy pants (-). came to hospital with a convulsion 30 minute before admission. .
physical examination. There is no hemaconcentration. this patient is diagnosed as complex febrile convulsion and mild-moderat malnutrition. and if the convulsion occurs. during the convulsion.00 in 3rd day.5% BH/A = 71/79 x 100% = 89.000 in 1st day. The laboratory examination also revealed an abnormality. Nutritional Discussion Here is the nutritional status of the patient: BW/A = 8/10. and before had a convulsion. she got a diazepam per oral three times a day 0. we can give her a paracetamol supp per rectal. The diagnosis of the mild-moderate malnutrition is mostly based on the antropometric measurement. Diagnosis Discussion The diagnosis of complex febrile convulsion was based on the anamnesis. 123. Intra venous line therapy was given KAEN 1 B for maintanance fluid body and to reduce a fever.6 x 100% = 75. we can give her a diazepam per rectal 10 mg. the temperature about 39°c. A blood glucose test and electrolyte blood analysis if there is an intracranial causes. And therapy for convulsion. and if she still has a fever. Treatment Discussion The management treatment. and patient was unconscious.8 % BW/BH = 8/10. and three times in 24 hours. Moreover. From physical examination. the patient must have a lumbar puncture.000 in 4th day. the parents also stated that she doesn’t eat much. there is a fever. 10 drops per minute. 95. There is also another diagnosis accompanying a complex febrile convulsion. From the anamnesis. the type of convulsion is tonic clonic. it was found that the patient has sign of convulsion. from 159.4 % 11 . trombositopenia. she had a fever.8 mg. because we have to know is there any bacterial or viral infection in serebrospinal fluid.9 x 100% = 73. Later. which is mildmoderate malnutrition. Paracetamol oral was given for maintaining the temperature.Chapter III Case Discussion The patient is a 16 months old girl with a sudden convulsion since 30 minutes before hospital admission. The BW/BH showed that the patient has a mild-moderate malutritional status.
The ideal body weight for the height of 71 cm is 10. we can calculate the daily calorie requirement. Therefore. From above data. The calorie requirement for 9 months old child is 110 kcal/kgBW/day. 110 kcal/kgBW/day. the total calorie is 1199 kcal/day.9 multiplied by the calorie requirement of a 9 months old child. being the ideal body weight of 10.9 kg. the height age of the patient is 9 months old. Therefore. 12 . Moreover.From the calculation above. the height of 71 cm is actually the height of 9 months old. we can see that the patient has mild-moderate malnutrition status.
2007. Pediatrics. 2009. 3. Complex febrile convulsion. Febrile Seizures. Downloaded from http://emedicine.com/article/801117-overview 2. 2007. In Nelson Essentials of Pediatrics ed 5th.References 1. Elsevier. 13 . WB Saunders Publisher. In Kliegman: Nelson Textbook of Pediatrics. Grace M Young.medscape. Febrile seizures. Saunders.
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