This case study examines the presentation, assessment, and management of a 2-year-old child experiencing a seizure at home. The assessment explores the provisional diagnosis, differential diagnoses, underlying

This case study examines the presentation, assessment, and management of a 2-year-old child experiencing a seizure at home. The assessment explores the provisional diagnosis, differential diagnoses, underlying pathophysiology, and the approach to treatment and education of the family and community. The scenario highlights the importance of rapid recognition, critical thinking, and adherence to clinical guidelines in paediatric emergency care.

Provisional Diagnosis

The working diagnosis for this case is a febrile seizure secondary to a middle ear infection with potential sepsis. This diagnosis is based on the sudden onset of a generalised seizure in a febrile child, in combination with recent symptoms of infection and irritability. The diagnosis is supported by:

• Age of patient: Febrile seizures are most common in children aged 6 months to 5 years.
• Fever: The child presented with a tympanic temperature of 39.9°C, indicative of a significant pyrexia.
• Seizure characteristics: A generalized seizure lasting approximately one minute, followed by postictal lethargy and limpness.
• History of recent infection: The mother reported the child had been unwell, refusing food and fluids, and had pain with pressure over the left tragus, suggesting otitis media.

These elements collectively support the provisional diagnosis of a simple febrile seizure, while acknowledging the need to rule out complications such as sepsis or intracranial pathology.

Distinctive Elements Leading to Diagnosis

Several clinical and historical elements point toward febrile seizure as the primary diagnosis:

1. Age-appropriate presentation: The child is 2 years old, fitting the typical age range for febrile seizures.
2. Fever and preceding illness: The child had a high-grade fever (39.9°C) with signs of upper respiratory infection, consistent with infections commonly triggering febrile seizures.
3. Seizure characteristics: A generalized tonic-clonic seizure lasting less than five minutes with no incontinence or focal deficits, typical for simple febrile seizures.
4. Postictal recovery: The child became limp and unresponsive briefly but quickly regained alertness, characteristic of a simple febrile seizure.

These features help differentiate febrile seizures from more serious neurological conditions.

Differential Diagnoses

1. Meningococcal Infection

Rationale for consideration: Meningococcal infections can present with fever, lethargy, irritability, and seizures. Rapid progression and high mortality necessitate exclusion.

Signs ruling out meningococcal infection in this case:

• No purpuric or petechial rash noted.
• No neck stiffness, photophobia, or bulging fontanelle.
• Child was alert postictally and had stable vital signs, without evidence of circulatory collapse.

2. Epilepsy

Rationale for consideration: Epileptic seizures may present in young children without fever. History of previous unprovoked seizures would suggest epilepsy.

Signs ruling out epilepsy in this case:

• Seizure was provoked by fever, not spontaneous.
• No previous history of recurrent seizures or abnormal neurological development.
• Postictal phase and rapid return to baseline are consistent with febrile seizure, not epilepsy.

Pathophysiology

Febrile seizures are convulsions triggered by a rapid rise in body temperature, typically associated with viral or bacterial infections. The underlying mechanisms include:

1. Immature neural networks: Young children have developing neurons and synapses, which are more susceptible to hyperexcitability under febrile conditions.
2. Cytokine-mediated hyperthermia: Infection induces pyrogens such as interleukin-1 (IL-1), which act on the hypothalamus to raise body temperature. High temperatures can alter neuronal firing, triggering generalized seizures.
3. Infection-related triggers: Otitis media, as indicated by tenderness over the left tragus, produces localized inflammation and systemic immune responses, contributing to fever and seizure risk.

Link to case presentation:

• Child’s high-grade fever (39.9°C) correlates with pyrogen-induced neuronal excitability.
• Previous refusal of food and fluids and irritability reflects systemic infection.
• Generalized seizure and postictal limpness match the pathophysiological process of transient, fever-induced neuronal hyperexcitability.

Patient Assessment and Treatment

Initial Assessment (ACTAS Guidelines)

Following ACT Ambulance (ACTAS) protocols, the patient was assessed using the ABCDE approach:

1. Airway: Patent, no obstruction observed.
2. Breathing: Respiratory rate 32/min; spontaneous and unlabored.
3. Circulation: HR 164 bpm via apex beat, extremities warm and flushed; peripheral perfusion adequate.
4. Disability: GCS 13 (V=crying, M=purposeful movement, E=3), pupils equal and reactive.
5. Environment/Exposure: High temperature recorded; warm summer conditions noted.

Additional observations included ear tenderness, irritability, and postictal recovery.

On-Scene Management

1. Seizure management:
   • Positioning the child laterally to prevent aspiration.
   • Monitoring airway, breathing, and circulation continuously.
   • Ensuring rapid access to medications if prolonged seizure (>5 min) occurs, per ACTAS paediatric seizure protocol.
2. Temperature management:
   • Removal of excess clothing and use of cool compresses.
   • Administration of paracetamol as indicated by the mother’s report and ACTAS dosing guidelines.
3. Hydration and monitoring:
   • Encouraging fluid intake where tolerated.
   • Monitoring vital signs and neurological status frequently.
4. Rapid transport:
   • Child transported to the nearest emergency department for further evaluation, particularly to assess for potential sepsis given recent infection and high fever.

Community and Family Education

Following the episode, community and family education focused on:

1. Understanding febrile seizures:
   • Explaining that febrile seizures are generally benign and self-limiting in children aged 6 months to 5 years.
   • Emphasising triggers such as rapid temperature increases from infections like otitis media.
2. Home first aid:
   • Placing a child on their side during a seizure.
   • Avoiding restraint, insertion of objects, or liquids during a seizure.
   • Recording seizure duration and characteristics for healthcare providers.
3. Recognising warning signs:
   • Persistent high fever, lethargy, respiratory distress, or signs of dehydration should prompt urgent medical attention.
   • Educating on early recognition of sepsis indicators, such as poor perfusion, hypotension, or altered consciousness.
4. Parental empowerment:
   • Encouraging parents to maintain calm, ensure safe environments, and seek timely medical assessment.
   • Reinforcing adherence to vaccination schedules to prevent infections that could trigger febrile seizures.
5. Community awareness:
   • Presentation at mothers’ groups or local health forums to inform other caregivers about febrile seizures and emergency response strategies.