1. An Audit of the management of a First Afebrile Seizure in childhood.
Boyle MA, Chuckwu J, Boyle MC, Connolly A, Webb D.
Paediatric Neurology Development
The National Children’s Hospital, Dublin, Ireland.
INTRODUCTION
Afebrile seizure is a common presentation
to paediatric emergency departments.
International guidelines on management
of such presentations allow for judicious
use of imaging and appropriate investigations.
RESULTS
JUNE 07 – DEC 08
26 Children. 13 boys, 13 girls
Age range from 1 month to 13yrs
Average age 7 yrs
No case achieved full concordance with the devised standards
Average score was 13 (Range 5 -17)
History well documented – avg score 2 (of 3)
Seizures were well documented – avg score 6 (of 8) 75% concordance w guidelines.
Investigation compliance was poor – 53% avg score 4.26 (of 8)
Concordance with management at discharge standards, poor at 25% - avg score 0.7 (of 3)
JAN 10 – JUNE 10
14 children. 8 boys, 6 girls
Age range from 6 months to 13yrs
Average age 4.8yrs
No case achieved full concordance with devised standards
Average score 16 (Range 13 – 20)
History well documented avg score 2 (of 3)
Seizures were well described – avg 7.7 (of 8) (97% concordance)
Compliance with guidelines on investigation of the first afebrile seizure in childhood improved – avg 5.6 (of 8) ~70% concordance
Concordance with management at discharge standards, avg 1.3 (43% concordance)
NICE Guidelines 2004
Review by specialist in management of
epilepsies to ensure precise & early diagnosis
EEG – to support a dx of epilepsy.
Neuroimaging – not routinely
MRI > CT. Of most value in under 2’s, history
suggestive of focal onset, seizure’s persist
after 1st line tx.
Blds & Urine biochem - discretion of specialist
AAN GUIDELINES 2003
Labs
U&E/bld glu/Mg/Ca/FBC – intuitive, evidence for same not strong
Labs – guided by case and hx. Glu, Ca and U&E most important
EEG – standard recommendation.
NeuroImaging – not routine.
OBJECTIVE
To compare the management of first
Afebrile seizures with internationally
recognized standards in an Irish tertiary paediatric setting.
Score
CONCLUSION
Presentation with first afebrile seizures is common in childhood.
We have demonstrated a lack of concordance with international guidelines on management of the first afebrile seizure in our institution.
Improvement noted between the 2 periods especially in area of investigation and discharge management.
Discharge management and advice remains poor with often no documentation regarding use of rescue meds or safety precautions.
Investigation improvements in area of requesting EEG on first event and improvement in the appropriate use of imaging
We now intend to provide further guidance on this topic and introduce an information pack at discharge before repeating the audit cycle.
METHODS
Records of first afebrile seizure presenting
to a Paediatric Emergency Department
period between June 2007 and December
2008 were identified through interrogation
of emergency department admission books
and Paediatric ward ledgers.
Infants older than one month up to over 15
years were included
Management standards were devised from
a compilation of British (NICE 2004)1 and
North American (AAN 2003)2 guidelines.
The standards comprised 3 principle areas:
(i) the medical record and seizure documentation
(ii) investigations recorded and
(iii) documentation of management at discharge.
Complete concordance with the
standards would accrue a score of 21/21.
Relevant patient charts were reviewed,
assessing medical and nursing notes.
The audit was repeated over the period
Jan to June 2010.
Patients
REFERENCES
The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care. CG20.
Practice parameter: Evaluating a first nonfebrile seizure in children. Hirtz D et al. NEUROLOGY 2000;55:616–623