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21 month old with 9 seizures in 18 hours
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21 month old with 9 seizures in 18 hours

Our 21 mohth old daugther woke up with a stomach bug, had vomited several times during the day, and was running a low grade fever, about 100. She was given tylenol around noon. At 6:30 pm she suffered a 60 second seizure which according to descriptions was much like many febrile seizures. She stiffened, her eyes rolled back, she stopped breathing and came to about 60 seconds later. There was no convulsing. She was brought to the emergency room, where they suspected a febrile seizure. 1 1/2 hours later she had another seizure.  The ER suggested this could not be febrile because of the multiple occurances of short seizures (clearly a mistatement, as it could have been complex febrile). She was not administered a drug of any kind and by 5am the next day had seized about 5 times (roughly 1 1/2 hour intervals). Post seizure recovery was fast, minutes, though after a few post ictal drowsines became more pronounced. She was then put on an IV of phenytoin.  She had a seizure around 7:45am An EEG was done and came back normal. Fever remained low 99-101.4, but pronounced temperature changes were felt just prior to seizures, but not recorded.  At around noon, another seizure, at which point Phenol Barbitol was added. No seizures occured after the Phenol Barb, though Ataxia presentned (upper body balance). A lumbar puncture was done, eliminating meningitis. After a hospital transfer, an MRI was done the next day as was an EEG. MRI normal. EEG showed some focal slowing in the right hemisphere. The neurologist felt is was some benign form of focal seizure disorder/epilepsy and trileptal was prescribed.

My question is, does elimination of complex febrile in this case seem to be premature? The seizure fit complex febrile, there was a fever, tylenol could have lowered initial fever (academic evidence suggests while tylenol lowers fevers, does not stop occurence of febrile seizures), diazapam was never delivered which likely would have prevented the multiple seizures earlier. Also it is my understanding that 2/3 of children that have post-ictal eeg abnormalities in the first few days, but only 8% over 2 weeks later. So, is the focal finding relevant?

Is no medicine and rectal diazapam on hand a better initial follow up to this situation?

Finally, on Trileptal the child is having some hand and foot twitching at night. This has never been observed, including while on phenytoin or phenal barb. It has been 6 days since initial seizure onset. Could the twitching be a side effect of trileptal?
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