Febrile SeizureAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

481 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx51

Event characterization

›Seizure event details

›Witness description

›Generalized versus focal onset features

›Eye deviation

›Asymmetric limb movements

›Speech arrest

›Posturing

›Duration estimate in minutes

›Less than 5 minutes

›5 to 15 minutes

›Greater than 15 minutes

›Number of seizures in 24 hours

›Single event

›More than 1 event

›Return to baseline

›Immediate baseline

›Prolonged postictal phase

›Persistent altered mental status

›Injury and aspiration risk

›Head strike

›Tongue bite

›Vomiting

Febrile illness context

›Fever and infection timeline

›Fever onset relative to seizure

›First fever noticed after seizure

›Fever present before seizure

›Maximum temperature if known

›Measured at home

›Measured in ED

›Antipyretic exposure

›Acetaminophen timing

›Ibuprofen timing

›Source symptoms

›URI symptoms

›Otalgia

›Vomiting

›Diarrhea

›Dysuria

›Rash

OPQRST

›OPQRST not typically applicable

›Seizure is an event rather than a pain symptom

›Use event characterization and fever context instead

Associated symptoms

›Neurologic and systemic associated symptoms

›Headache

›Neck stiffness

›Photophobia

›Persistent vomiting

›Lethargy out of proportion to typical postictal state

›Focal weakness

›Recent trauma

›Possible toxic ingestion

02Alarm Features/alarm32

Immediate escalation triggers

›Critical features

›Ongoing convulsive seizure or recurrent without recovery

›Treat as convulsive status epilepticus

›Resuscitation bay and full monitoring

›Airway or breathing compromise

›Apnea

›Hypoxemia despite oxygen

›Circulatory instability

›Hypotension

›Signs of shock

›Persistent altered mental status

›Not at baseline after expected postictal period

›Progressive decline

›Concern for CNS infection

›Nuchal rigidity

›Petechiae or purpura

›Bulging fontanelle in infant

High risk seizure features

›Complex or atypical febrile seizure features

›Duration greater than 15 minutes

›Focal onset or focal exam findings

›More than 1 seizure within 24 hours

›Age outside typical range

›Younger than 6 months

›Older than 5 years

›First seizure with abnormal neurologic baseline

›Known developmental delay

›Known epilepsy

Vital sign danger thresholds

›Abnormal vitals prompting broadened evaluation

›Persistent tachycardia after defervescence

›Hypotension for age

›Persistent hypoxemia

›Hyperthermia with concern for heat illness or toxicologic syndrome

03Medications/meds18

Current and recent exposures

›Medication reconciliation

›Antipyretics

›Acetaminophen

›Ibuprofen

›Recent antibiotics

›Beta lactams

›Macrolides

›Antiseizure medications

›Levetiracetam

›Valproate

›Carbamazepine

›Sedatives and cough cold products

›Antihistamines

›Dextromethorphan

Rescue medication access

›Home rescue plan if known epilepsy or prior complex febrile seizure

›Rectal diazepam availability

›Intranasal midazolam availability

›Caregiver training and last use

04Diet/diet12

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Normal intake

›Vomiting limiting fluids

›Diarrhea limiting fluids

›Hydration indicators

›Urine output decreased

›Tears present

›Dry mucous membranes

Exposures

›Potential contributors

›Caffeine or energy drink exposure in older child

›Possible toxic ingestion access

05Review of Systems/ros16

Infectious symptoms

›Infection focused ROS

›Cough

›Rhinorrhea

›Sore throat

›Ear pain

›Rash

›Vomiting

›Diarrhea

›Dysuria

Neurologic symptoms

›Neuro ROS

›Headache

›Neck pain or stiffness

›Photophobia

›Persistent confusion

›Weakness

›Gait change

06Collateral History and Family History/chafh13

Source and reliability

›Collateral details

›Primary witness present

›EMS report available

›Video available

›Reliability concerns

Family and social context

›Family history and home context

›Febrile seizures in first degree relatives

›Epilepsy in first degree relatives (G40.909)

›Inherited channelopathies

›Long QT syndrome (I45.81)

›Brugada syndrome (I49.8)

›Sick contacts in household

›Supervision reliability for discharge

07Risk Factors/rf16

Patient factors

›Seizure recurrence and epilepsy risk modifiers

›Prior febrile seizure (R56.0)

›Neurodevelopmental delay (F88)

›Known CNS abnormality

›Prematurity history

›Family history of epilepsy

Infection and exposure risks

›Infection and meningitis risks

›Incomplete immunizations

›Hib series incomplete

›Pneumococcal series incomplete

›Recent antibiotics before presentation

›Recent travel or outbreak exposure

›Toxicologic risks

›Access to medications at home

›Cannabis edible access

›Household chemicals access

08Differential Diagnosis/ddx53

Life threatening

›Life threatening etiologies

›CNS infection

›Bacterial meningitis (G00.9)

›Encephalitis (G04.90)

›Key clues

›Nuchal rigidity

›Persistent altered mental status

›Petechiae or purpura

›Convulsive status epilepticus (G40.901)

›Key clues

›Seizure longer than 5 minutes

›Recurrent seizures without recovery

›Hypoglycemia (E16.2)

›Key clues

›Poor intake

›Diaphoresis

›Persistent altered mental status

›Toxic ingestion

›Key clues

›Mixed toxidrome signs

›Access history

›Intracranial hemorrhage or trauma

›Key clues

›Trauma history

›Focal deficits

Common

›Common etiologies

›Simple febrile seizure (R56.0)

›Typical features

›Generalized convulsion

›Less than 15 minutes

›Single seizure in 24 hours

›Normal neurologic baseline

›Viral illness with fever

›URI

›Viral gastroenteritis

›Otitis media (H66.90)

›UTI (N39.0)

Less common

›Less common etiologies

›Complex febrile seizure (R56.0)

›Typical features

›Focal

›More than 15 minutes

›More than 1 in 24 hours

›First unprovoked seizure coincident with fever (R56.9)

›Key clues

›Fever low grade or incidental

›Focal onset

›Electrolyte disturbance

›Hyponatremia (E87.1)

›Hypocalcemia (E83.51)

›Heat illness

›Environmental exposure history

›Hyperthermia not typical fever pattern

09Past Medical History/pmh15

Baseline neurologic and developmental history

›Baseline status

›Neurodevelopmental milestones

›Prior seizures

›Prior febrile seizures

›Known epilepsy diagnosis (G40.909)

Prior infections and immunizations

›Infectious history

›Immunization status

›Hib up to date

›Pneumococcal up to date

›Prior CNS infection

›Recent antibiotic courses

Procedures and devices

›Relevant procedures

›VP shunt

›Cochlear implant

›Recent lumbar puncture

10Physical Exam/exam42

General and vitals

›General assessment

›Appearance

›Toxic

›Nontoxic

›Level of consciousness

›At baseline

›Postictal

›Persistent altered

›Vital sign interpretation

›Fever pattern

›Perfusion status

›Respiratory effort

Neurologic exam

›Focused neurologic exam

›Pupils and gaze

›Anisocoria

›Gaze deviation

›Tone and motor symmetry

›Hemiparesis

›Todd paresis

›Meningeal signs

›Nuchal rigidity

›Photophobia behavior

›Fontanelle in infants

›Bulging

›Flat

Head to toe infectious source

›Source exam

›HEENT

›Otitis media findings

›Pharyngeal exudate

›Skin

›Petechiae

›Purpura

›Vesicular rash

›Lungs

›Focal crackles

›Increased work of breathing

›Abdomen

›Tenderness

›Hepatosplenomegaly

›Hydration

›Dry mucous membranes

›Delayed capillary refill

11Lab Studies/labs23

Point of care and targeted labs

›Targeted testing strategy

›Glucose point of care

›Indicated if persistent altered mental status

›Indicated if prolonged seizure

›Electrolytes and calcium

›Indicated if persistent altered mental status

›Indicated if dehydration or significant vomiting or diarrhea

›CBC

›Indicated if toxic appearance

›Indicated if concern for serious bacterial infection

›Blood culture

›Indicated if sepsis concern

›Indicated if meningitis concern

›Urinalysis and urine culture

›Indicated if no clear source of fever

›Indicated in higher risk age groups per local pathway

Lumbar puncture adjunct labs

›CSF related considerations

›LP considered if meningitis or encephalitis concern

›Persistent altered mental status

›Meningeal signs

›LP not routine for simple febrile seizure with normal exam

›Normal return to baseline

›No meningeal signs

12Imaging/img27

Scoring Systems

›Imaging decision framing

›No validated imaging score for febrile seizure alone

›Imaging driven by trauma concern or focal neurologic findings

›Local protocol dependent pathways

›Fever without source pathways

›Meningitis risk pathways

MRI

›MRI brain considerations

›Indications

›Persistent focal deficits

›Abnormal neurologic baseline with new seizure pattern

›Concern for encephalitis after initial stabilization

›Contraindications and feasibility

›Unstable airway or breathing

›Need for sedation risk assessment

›CT head considerations

›Indications

›Concern for intracranial hemorrhage or trauma

›Persistent focal deficit not consistent with transient Todd paresis

›Concern for raised intracranial pressure signs

›Cautions

›Radiation exposure

›Avoid routine CT in simple febrile seizure with normal exam

Ultrasound

›Ultrasound role

›Limited role for seizure itself

›Infection source evaluation when appropriate

›Lung ultrasound for pneumonia pattern

›Renal bladder ultrasound in selected UTI pathways

13Special Tests/spec17

Bedside diagnostics

›Bedside and procedural tests

›Respiratory viral testing

›Use when result changes isolation or disposition

›Local protocol dependent

›Toxicology testing

›Use when ingestion suspected

›Interpret in context of clinical toxidrome

›EEG

›Not routine for simple febrile seizure

›Consider for recurrent complex events or concern for epilepsy

Infection focused tests

›Source directed testing

›Rapid strep testing

›Use when pharyngitis features present

›Avoid when viral features dominate

›Chest radiograph as test

›Use when focal lung findings

›Use when hypoxemia present

14ECG/ecg10

When relevant

›ECG indications in seizure with fever

›Syncope versus seizure uncertainty

›Family history of sudden cardiac death

›Exposure to QT prolonging agents

›Persistent tachycardia not explained by fever

High risk patterns

›ECG red flags

›Prolonged QT

›Brugada pattern

›Preexcitation pattern

›Ventricular arrhythmia

15Assessment/ax32

Classification

›Febrile seizure classification

›Simple febrile seizure (R56.0)

›Generalized

›Less than 15 minutes

›Single in 24 hours

›Normal baseline and exam

›Complex febrile seizure (R56.0)

›Focal features

›Greater than 15 minutes

›More than 1 in 24 hours

Complications and alternate diagnoses

›Must not miss considerations

›CNS infection

›Supporting features

›Toxic appearance

›Persistent altered mental status

›Metabolic derangement

›Supporting features

›Dehydration

›Persistent altered mental status

›Trauma

›Supporting features

›Head injury

›Focal deficits

Risk stratification

›Disposition risk framing

›Low risk

›Simple febrile seizure

›Normal exam

›Identified benign source or reassuring evaluation

›Higher risk

›Complex features

›Unreliable return to baseline

›Concern for serious bacterial infection

16Plan/plan44

Approach to the critical patient

›First 5 minutes workflow

›Airway and breathing

›Oxygen if hypoxemic

›Suction if secretions

›Circulation and access

›IV access if ongoing seizure or recurrent events

›Intraosseous access if IV delayed and unstable

›Monitoring

›Continuous pulse oximetry

›Cardiac monitor

›Temperature

›Glucose

›Point of care glucose if not at baseline

›Dextrose if hypoglycemia per local pediatric dosing

Acute seizure management

›If active seizure

›Benzodiazepine first line

›Midazolam IN 0.2 mg per kg

›Midazolam IM 0.2 mg per kg

›Lorazepam IV 0.1 mg per kg

›Maximum single dose per local protocol

›If seizure persists after 2 benzodiazepine doses

›Treat as convulsive status epilepticus

›Second line antiseizure medication per pathway

›Levetiracetam IV 40 to 60 mg per kg

›Fosphenytoin IV 20 mg PE per kg

›Valproate IV 20 to 40 mg per kg

Fever and comfort

›Antipyretics for comfort

›Acetaminophen 15 mg per kg PO or PR

›Ibuprofen 10 mg per kg PO

›Hydration support

›Oral rehydration if tolerated

›IV isotonic fluids if dehydrated or poor intake

Diagnostic plan

›Testing tied to risk

›No routine labs or imaging for simple febrile seizure with normal exam

›Infection source evaluation guided by age and exam

›Urine testing when no source or higher risk group

›Blood work when toxic or sepsis concern

›LP if meningitis or encephalitis concern

›Consider neuroimaging before LP if raised intracranial pressure concern

Reassessment loop

›Reassessment targets

›Mental status trend every 15 to 30 minutes until baseline

›Repeat vitals after defervescence

›Tolerance of oral intake before discharge

›New focal deficits trigger broadened workup

17Disposition/dispo21

Discharge criteria

›Discharge appropriate when all present

›Returned to neurologic baseline

›Normal age appropriate exam

›Simple febrile seizure pattern or reassuring complex evaluation

›Caregiver reliable and understands return precautions

›Follow up plan established

Observation or admission criteria

›Observation or inpatient care when present

›Complex febrile seizure features with uncertain course

›Persistent altered mental status

›Recurrent seizures in ED

›Concern for CNS infection or serious bacterial infection

›Inability to maintain hydration

›Unsafe social situation or unreliable supervision

ICU and transfer criteria

›ICU level care triggers

›Convulsive status epilepticus

›Airway compromise requiring advanced airway support

›Hemodynamic instability

›Refractory seizures requiring continuous infusion per protocol

›Transfer triggers

›Need for pediatric neurology not available

›Need for ICU not available locally

18Discharge Instructions/di24

Copy discharge instructions

›Febrile seizure summary

›A febrile seizure is a seizure that can happen in young children when they have a fever

›Most febrile seizures stop on their own and do not cause brain damage

›What to do if another seizure happens

›Place your child on their side on a safe surface

›Do not put anything in the mouth

›Time the seizure using a clock or phone timer

›Call emergency services if the seizure lasts more than 5 minutes

›Fever care

›Use acetaminophen or ibuprofen for comfort as directed for your child weight

›Encourage fluids

›Follow up

›Primary care follow up within 1 to 2 days

›Neurology follow up if recommended for complex features

›Return to ED now if any occur

›Another seizure within 24 hours

›Seizure longer than 5 minutes

›Trouble breathing or turning blue

›Not acting like usual after the seizure

›Stiff neck

›Severe headache

›New weakness on one side

›Purple rash or widespread spots

›Signs of dehydration

19References/r15

Guidelines and key sources

›Febrile seizures guideline American Academy of Pediatrics 2011

›Evaluation focused on identifying fever source

›LP and neuroimaging not routine for simple febrile seizure with normal exam

›Fever in under 5s assessment and management NICE guideline updated 2019

›Age based serious illness features guide testing and disposition

›Local protocol dependent implementation

›Status epilepticus definition and classification International League Against Epilepsy 2015

›Time based definition supports early escalation after 5 minutes

›Framework for convulsive status pathway

›Convulsive status epilepticus management American Epilepsy Society guideline 2016

›Benzodiazepine first line

›Second line antiseizure options include levetiracetam fosphenytoin valproate

›Practice guideline update for first seizure evaluation American Academy of Neurology 2015

›EEG and imaging guided by focal findings and recurrence risk

›Not routine for simple febrile seizure

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Febrile SeizureAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

481 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx51

Event characterization

›Seizure event details

›Witness description

›Generalized versus focal onset features

›Eye deviation

›Asymmetric limb movements

›Speech arrest

›Posturing

›Duration estimate in minutes

›Less than 5 minutes

›5 to 15 minutes

›Greater than 15 minutes

›Number of seizures in 24 hours

›Single event

›More than 1 event

›Return to baseline

›Immediate baseline

›Prolonged postictal phase

›Persistent altered mental status

›Injury and aspiration risk

›Head strike

›Tongue bite

›Vomiting

Febrile illness context

›Fever and infection timeline

›Fever onset relative to seizure

›First fever noticed after seizure

›Fever present before seizure

›Maximum temperature if known

›Measured at home

›Measured in ED

›Antipyretic exposure

›Acetaminophen timing

›Ibuprofen timing

›Source symptoms

›URI symptoms

›Otalgia

›Vomiting

›Diarrhea

›Dysuria

›Rash

OPQRST

›OPQRST not typically applicable

›Seizure is an event rather than a pain symptom

›Use event characterization and fever context instead

Associated symptoms

›Neurologic and systemic associated symptoms

›Headache

›Neck stiffness

›Photophobia

›Persistent vomiting

›Lethargy out of proportion to typical postictal state

›Focal weakness

›Recent trauma

›Possible toxic ingestion

02Alarm Features/alarm32

Immediate escalation triggers

›Critical features

›Ongoing convulsive seizure or recurrent without recovery

›Treat as convulsive status epilepticus

›Resuscitation bay and full monitoring

›Airway or breathing compromise

›Apnea

›Hypoxemia despite oxygen

›Circulatory instability

›Hypotension

›Signs of shock

›Persistent altered mental status

›Not at baseline after expected postictal period

›Progressive decline

›Concern for CNS infection

›Nuchal rigidity

›Petechiae or purpura

›Bulging fontanelle in infant

High risk seizure features

›Complex or atypical febrile seizure features

›Duration greater than 15 minutes

›Focal onset or focal exam findings

›More than 1 seizure within 24 hours

›Age outside typical range

›Younger than 6 months

›Older than 5 years

›First seizure with abnormal neurologic baseline

›Known developmental delay

›Known epilepsy

Vital sign danger thresholds

›Abnormal vitals prompting broadened evaluation

›Persistent tachycardia after defervescence

›Hypotension for age

›Persistent hypoxemia

›Hyperthermia with concern for heat illness or toxicologic syndrome

03Medications/meds18

Current and recent exposures

›Medication reconciliation

›Antipyretics

›Acetaminophen

›Ibuprofen

›Recent antibiotics

›Beta lactams

›Macrolides

›Antiseizure medications

›Levetiracetam

›Valproate

›Carbamazepine

›Sedatives and cough cold products

›Antihistamines

›Dextromethorphan

Rescue medication access

›Home rescue plan if known epilepsy or prior complex febrile seizure

›Rectal diazepam availability

›Intranasal midazolam availability

›Caregiver training and last use

04Diet/diet12

Intake and hydration

›Recent intake pattern

›Poor oral intake

›Normal intake

›Vomiting limiting fluids

›Diarrhea limiting fluids

›Hydration indicators

›Urine output decreased

›Tears present

›Dry mucous membranes

Exposures

›Potential contributors

›Caffeine or energy drink exposure in older child

›Possible toxic ingestion access

05Review of Systems/ros16

Infectious symptoms

›Infection focused ROS

›Cough

›Rhinorrhea

›Sore throat

›Ear pain

›Rash

›Vomiting

›Diarrhea

›Dysuria

Neurologic symptoms

›Neuro ROS

›Headache

›Neck pain or stiffness

›Photophobia

›Persistent confusion

›Weakness

›Gait change

06Collateral History and Family History/chafh13

Source and reliability

›Collateral details

›Primary witness present

›EMS report available

›Video available

›Reliability concerns

Family and social context

›Family history and home context

›Febrile seizures in first degree relatives

›Epilepsy in first degree relatives (G40.909)

›Inherited channelopathies

›Long QT syndrome (I45.81)

›Brugada syndrome (I49.8)

›Sick contacts in household

›Supervision reliability for discharge

07Risk Factors/rf16

Patient factors

›Seizure recurrence and epilepsy risk modifiers

›Prior febrile seizure (R56.0)

›Neurodevelopmental delay (F88)

›Known CNS abnormality

›Prematurity history

›Family history of epilepsy

Infection and exposure risks

›Infection and meningitis risks

›Incomplete immunizations

›Hib series incomplete

›Pneumococcal series incomplete

›Recent antibiotics before presentation

›Recent travel or outbreak exposure

›Toxicologic risks

›Access to medications at home

›Cannabis edible access

›Household chemicals access

08Differential Diagnosis/ddx53

Life threatening

›Life threatening etiologies

›CNS infection

›Bacterial meningitis (G00.9)

›Encephalitis (G04.90)

›Key clues

›Nuchal rigidity

›Persistent altered mental status

›Petechiae or purpura

›Convulsive status epilepticus (G40.901)

›Key clues

›Seizure longer than 5 minutes

›Recurrent seizures without recovery

›Hypoglycemia (E16.2)

›Key clues

›Poor intake

›Diaphoresis

›Persistent altered mental status

›Toxic ingestion

›Key clues

›Mixed toxidrome signs

›Access history

›Intracranial hemorrhage or trauma

›Key clues

›Trauma history

›Focal deficits

Common

›Common etiologies

›Simple febrile seizure (R56.0)

›Typical features

›Generalized convulsion

›Less than 15 minutes

›Single seizure in 24 hours

›Normal neurologic baseline

›Viral illness with fever

›URI

›Viral gastroenteritis

›Otitis media (H66.90)

›UTI (N39.0)

Less common

›Less common etiologies

›Complex febrile seizure (R56.0)

›Typical features

›Focal

›More than 15 minutes

›More than 1 in 24 hours

›First unprovoked seizure coincident with fever (R56.9)

›Key clues

›Fever low grade or incidental

›Focal onset

›Electrolyte disturbance

›Hyponatremia (E87.1)

›Hypocalcemia (E83.51)

›Heat illness

›Environmental exposure history

›Hyperthermia not typical fever pattern

09Past Medical History/pmh15

Baseline neurologic and developmental history

›Baseline status

›Neurodevelopmental milestones

›Prior seizures

›Prior febrile seizures

›Known epilepsy diagnosis (G40.909)

Prior infections and immunizations

›Infectious history

›Immunization status

›Hib up to date

›Pneumococcal up to date

›Prior CNS infection

›Recent antibiotic courses

Procedures and devices

›Relevant procedures

›VP shunt

›Cochlear implant

›Recent lumbar puncture

10Physical Exam/exam42

General and vitals

›General assessment

›Appearance

›Toxic

›Nontoxic

›Level of consciousness

›At baseline

›Postictal

›Persistent altered

›Vital sign interpretation

›Fever pattern

›Perfusion status

›Respiratory effort

Neurologic exam

›Focused neurologic exam

›Pupils and gaze

›Anisocoria

›Gaze deviation

›Tone and motor symmetry

›Hemiparesis

›Todd paresis

›Meningeal signs

›Nuchal rigidity

›Photophobia behavior

›Fontanelle in infants

›Bulging

›Flat

Head to toe infectious source

›Source exam

›HEENT

›Otitis media findings

›Pharyngeal exudate

›Skin

›Petechiae

›Purpura

›Vesicular rash

›Lungs

›Focal crackles

›Increased work of breathing

›Abdomen

›Tenderness

›Hepatosplenomegaly

›Hydration

›Dry mucous membranes

›Delayed capillary refill

11Lab Studies/labs23

Point of care and targeted labs

›Targeted testing strategy

›Glucose point of care

›Indicated if persistent altered mental status

›Indicated if prolonged seizure

›Electrolytes and calcium

›Indicated if persistent altered mental status

›Indicated if dehydration or significant vomiting or diarrhea

›CBC

›Indicated if toxic appearance

›Indicated if concern for serious bacterial infection

›Blood culture

›Indicated if sepsis concern

›Indicated if meningitis concern

›Urinalysis and urine culture

›Indicated if no clear source of fever

›Indicated in higher risk age groups per local pathway

Lumbar puncture adjunct labs

›CSF related considerations

›LP considered if meningitis or encephalitis concern

›Persistent altered mental status

›Meningeal signs

›LP not routine for simple febrile seizure with normal exam

›Normal return to baseline

›No meningeal signs

12Imaging/img27

Scoring Systems

›Imaging decision framing

›No validated imaging score for febrile seizure alone

›Imaging driven by trauma concern or focal neurologic findings

›Local protocol dependent pathways

›Fever without source pathways

›Meningitis risk pathways

MRI

›MRI brain considerations

›Indications

›Persistent focal deficits

›Abnormal neurologic baseline with new seizure pattern

›Concern for encephalitis after initial stabilization

›Contraindications and feasibility

›Unstable airway or breathing

›Need for sedation risk assessment

›CT head considerations

›Indications

›Concern for intracranial hemorrhage or trauma

›Persistent focal deficit not consistent with transient Todd paresis

›Concern for raised intracranial pressure signs

›Cautions

›Radiation exposure

›Avoid routine CT in simple febrile seizure with normal exam

Ultrasound

›Ultrasound role

›Limited role for seizure itself

›Infection source evaluation when appropriate

›Lung ultrasound for pneumonia pattern

›Renal bladder ultrasound in selected UTI pathways

13Special Tests/spec17

Bedside diagnostics

›Bedside and procedural tests

›Respiratory viral testing

›Use when result changes isolation or disposition

›Local protocol dependent

›Toxicology testing

›Use when ingestion suspected

›Interpret in context of clinical toxidrome

›EEG

›Not routine for simple febrile seizure

›Consider for recurrent complex events or concern for epilepsy

Infection focused tests

›Source directed testing

›Rapid strep testing

›Use when pharyngitis features present

›Avoid when viral features dominate

›Chest radiograph as test

›Use when focal lung findings

›Use when hypoxemia present

14ECG/ecg10

When relevant

›ECG indications in seizure with fever

›Syncope versus seizure uncertainty

›Family history of sudden cardiac death

›Exposure to QT prolonging agents

›Persistent tachycardia not explained by fever

High risk patterns

›ECG red flags

›Prolonged QT

›Brugada pattern

›Preexcitation pattern

›Ventricular arrhythmia

15Assessment/ax32

Classification

›Febrile seizure classification

›Simple febrile seizure (R56.0)

›Generalized

›Less than 15 minutes

›Single in 24 hours

›Normal baseline and exam

›Complex febrile seizure (R56.0)

›Focal features

›Greater than 15 minutes

›More than 1 in 24 hours

Complications and alternate diagnoses

›Must not miss considerations

›CNS infection

›Supporting features

›Toxic appearance

›Persistent altered mental status

›Metabolic derangement

›Supporting features

›Dehydration

›Persistent altered mental status

›Trauma

›Supporting features

›Head injury

›Focal deficits

Risk stratification

›Disposition risk framing

›Low risk

›Simple febrile seizure

›Normal exam

›Identified benign source or reassuring evaluation

›Higher risk

›Complex features

›Unreliable return to baseline

›Concern for serious bacterial infection

16Plan/plan44

Approach to the critical patient

›First 5 minutes workflow

›Airway and breathing

›Oxygen if hypoxemic

›Suction if secretions

›Circulation and access

›IV access if ongoing seizure or recurrent events

›Intraosseous access if IV delayed and unstable

›Monitoring

›Continuous pulse oximetry

›Cardiac monitor

›Temperature

›Glucose

›Point of care glucose if not at baseline

›Dextrose if hypoglycemia per local pediatric dosing

Acute seizure management

›If active seizure

›Benzodiazepine first line

›Midazolam IN 0.2 mg per kg

›Midazolam IM 0.2 mg per kg

›Lorazepam IV 0.1 mg per kg

›Maximum single dose per local protocol

›If seizure persists after 2 benzodiazepine doses

›Treat as convulsive status epilepticus

›Second line antiseizure medication per pathway

›Levetiracetam IV 40 to 60 mg per kg

›Fosphenytoin IV 20 mg PE per kg

›Valproate IV 20 to 40 mg per kg

Fever and comfort

›Antipyretics for comfort

›Acetaminophen 15 mg per kg PO or PR

›Ibuprofen 10 mg per kg PO

›Hydration support

›Oral rehydration if tolerated

›IV isotonic fluids if dehydrated or poor intake

Diagnostic plan

›Testing tied to risk

›No routine labs or imaging for simple febrile seizure with normal exam

›Infection source evaluation guided by age and exam

›Urine testing when no source or higher risk group

›Blood work when toxic or sepsis concern

›LP if meningitis or encephalitis concern

›Consider neuroimaging before LP if raised intracranial pressure concern

Reassessment loop

›Reassessment targets

›Mental status trend every 15 to 30 minutes until baseline

›Repeat vitals after defervescence

›Tolerance of oral intake before discharge

›New focal deficits trigger broadened workup

17Disposition/dispo21

Discharge criteria

›Discharge appropriate when all present

›Returned to neurologic baseline

›Normal age appropriate exam

›Simple febrile seizure pattern or reassuring complex evaluation

›Caregiver reliable and understands return precautions

›Follow up plan established

Observation or admission criteria

›Observation or inpatient care when present

›Complex febrile seizure features with uncertain course

›Persistent altered mental status

›Recurrent seizures in ED

›Concern for CNS infection or serious bacterial infection

›Inability to maintain hydration

›Unsafe social situation or unreliable supervision

ICU and transfer criteria

›ICU level care triggers

›Convulsive status epilepticus

›Airway compromise requiring advanced airway support

›Hemodynamic instability

›Refractory seizures requiring continuous infusion per protocol

›Transfer triggers

›Need for pediatric neurology not available

›Need for ICU not available locally

18Discharge Instructions/di24

Copy discharge instructions

›Febrile seizure summary

›A febrile seizure is a seizure that can happen in young children when they have a fever

›Most febrile seizures stop on their own and do not cause brain damage

›What to do if another seizure happens

›Place your child on their side on a safe surface

›Do not put anything in the mouth

›Time the seizure using a clock or phone timer

›Call emergency services if the seizure lasts more than 5 minutes

›Fever care

›Use acetaminophen or ibuprofen for comfort as directed for your child weight

›Encourage fluids

›Follow up

›Primary care follow up within 1 to 2 days

›Neurology follow up if recommended for complex features

›Return to ED now if any occur

›Another seizure within 24 hours

›Seizure longer than 5 minutes

›Trouble breathing or turning blue

›Not acting like usual after the seizure

›Stiff neck

›Severe headache

›New weakness on one side

›Purple rash or widespread spots

›Signs of dehydration

19References/r15

Guidelines and key sources

›Febrile seizures guideline American Academy of Pediatrics 2011

›Evaluation focused on identifying fever source

›LP and neuroimaging not routine for simple febrile seizure with normal exam

›Fever in under 5s assessment and management NICE guideline updated 2019

›Age based serious illness features guide testing and disposition

›Local protocol dependent implementation

›Status epilepticus definition and classification International League Against Epilepsy 2015

›Time based definition supports early escalation after 5 minutes

›Framework for convulsive status pathway

›Convulsive status epilepticus management American Epilepsy Society guideline 2016

›Benzodiazepine first line

›Second line antiseizure options include levetiracetam fosphenytoin valproate

›Practice guideline update for first seizure evaluation American Academy of Neurology 2015

›EEG and imaging guided by focal findings and recurrence risk

›Not routine for simple febrile seizure

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.