Investigators at Tel-Aviv Sourasky Medical Center, and three other medical centers in Israel, obtained data, prospectively, on all children presenting in the emergency departments from January 2008 to March 2010 with prolonged febrile seizures. Information related to seizure semiology, treatment, and outcome was collected and reviewed centrally on a total of 60 children, median age 18.3 months (range 12-28), with a median seizure duration of 35 min (range 26-60), 43 (71.7%) lasting >30 min. Seizures had focal onset in 34 infants (57%). Ambulance service activated by 54 families (90%) had a median arrival time of 8 min (range 5-10). Of 33 (61%) children treated with AEDs by the ambulance paramedics, only 15 (45%) responded. Children treated with rectal diazepam were less likely to respond: Only 1 (11%) of 9 children receiving rectal diazepam responded compared with 11 (58%) of 19 who received intravenous diazepam. Thirty-one children (52%) were still seizing on arrival in the ED, and 38 were admitted to hospital. EEG in 37 (61.7%) was abnormal in 17, but referral for EEG was independent of age, seizure duration, focality, and multiple seizure type. Lumbar puncture (LP) was performed in 12 patients (20%), ages 3-35 months, and none showed bacterial meningitis. Of children undergoing LP, 50% were <18 months of age, seizures had longer mean duration (73.8 vs 42.4 min (p=0.001), and most had active seizures in ED. Focality of seizure was not associated with performance of LP. Predictors of prolonged FS (> 30 min) were an independent effect of intermittent seizure semiology and initial treatment with rectal diazepam (p=0.001). [1]

COMMENT. A prolonged febrile seizure (PFS), as defined in this study, is a subtype of the complex febrile seizure and one lasting >15 minutes. More recent data suggest that 10 minutes may be a more appropriate cutoff between the simple and complex FS [2]. A febrile seizure lasting >30 min is classified as febrile status epilepticus (FSE), accounting for 5-9% of febrile seizure patients. [3]

PFS and FSE may be associated with hippocampal injury, subsequent mesial temporal sclerosis, and temporal lobe epilepsy [4, 5]. In light of the increased risk of subsequent epilepsy, the acute management and prevention of PFS and FSE become highly important.

Rectal versus Intravenous Diazepam Treatment. The ineffectiveness of rectal diazepam in management of PFS reported in the Israel study is consistent with the findings in the UK, that control of status epilepticus with intravenous lorazepam was significantly superior to that with rectal diazepam [6]. In contrast, a retrospective analysis of a 30-month consecutive sample of ambulance-transported children in a large urban emergency medical service in San Francisco found rectal diazepam to be a simple, effective, and safe method of pre-hospital management of pediatric status epilepticus [7]. Compared with IV diazepam, rectal diazepam is easier to administer, and is equally efficacious and less likely to produce respiratory depression. Short duration of action is an important limitation of both treatments.