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  6. First Afebrile Seizure Management, Emergency Department, Paediatrics (130)
Important: please update your RDS app to version 4.7.3 Details with newsletter below.

Please update your RDS app to v4.7.3

We asked you in January to update to v4.7.2.  After the deployment planned for 27th February, this new update will be needed to ensure that you are able to download RDS toolkits even when the RDS website is not available. We will wait until as many users as possible have downloaded the new version before switching off the old system for app downloads and moving entirely to the new approach.

To check your current RDS version, click on the three dots bottom right of the RDS app screen. This takes you to a “More” page where you will see the version number. 

To update to the latest release:

 On iPhones – go to the Apple store, click on your profile icon top right, scroll down to see the apps waiting to be updated and update the RDS app.

On Android phones – these can vary, but try going to the Google Play store, click on your profile icon top right, click on “Manage apps and device”, select and update the RDS app.

Right Decision Service newsletter: February 2025

Welcome to the February 2025 update from the RDS team

1.     Next release of RDS

 

A new release of RDS is planned (subject to outcomes of current testing) for week beginning 24th February. This will deliver:

 

  • Fixes to mitigate the recurring glitches with the RDS admin area and the occasional brief user interface outages which have arisen following implementation of the new distributed technology infrastructure in December 2024.

 

  • Capability to embed content from Google calendar, Google Maps, Daily Motion, Twitter feeds, Microsoft Stream into RDS pages.

 

  • Capability to include simple multiplication in RDS calculators.

 

The release will also incorporate a number of small fixes, including:

  • Exporting of form within Medicines Sick Day Guidance in polypharmacy toolkit
  • Links to redundant content appearing in search in some RDS toolkits
  • Inclusion of accordion headers alongside accordion text in search result snippets.
  • Feedback form on mobile app.
  • Internal links on mobile app version of benzo tapering tool

 

We will let you know when the date and time for the new release are confirmed.

 

2.     New RDS developments

There is now the capability to publish toolkits on the web with left hand side navigation rather than tiles on the homepage. To use this feature, turn on the “Toggle navigation panel” option at the top of the Page settings menu at toolkit homepage level – see below. Please note that publication to downloadable mobile app for this type of navigation is still under development.

The Benzodiazepine tapering tool (https://rightdecisions.scot.nhs.uk/benzotapering) is now available as part of the RDS toolkit for the national benzodiazepine prescribing guidance developed by the Scottish Government Effective Prescribing team. The tool uses this national guidance developed with a wide-ranging multidisciplinary group. This should be used in combination with professional judgement and an understanding of the needs of the individual patient.

3.     Archiving and version control and new RDS Search and Browse interface

Due to the intensive work Tactuum has had to undertake on the new technology infrastructure has pushed back the delivery dates again and some new requirements have come out of the recent user acceptance testing. It now looks likely to be an April release for the search and browse interface. The archiving and version control functionality may be released earlier. We’ll keep you posted.

4.     Statistics

At the end of January, Olivia completed the generation of the latest set of usage statistics for all RDS toolkits. If you would like a copy of the stats for your toolkit, please contact Olivia.graham@nhs.scot .

 

5.     Review of content past its review date

We have now generated reports of all RDS toolkit content that has exceeded its review date by 6 months or more. We will be in touch later this month with toolkit owners and editors to agree the plan for updating or withdrawing out of date content.

 

6.     Toolkits in development

Some important toolkits in development by the RDS team include:

  • National CVD prevention pathways – due for release end of March 2025.
  • National respiratory pathways, optimal cancer diagnostic pathways and cancer prehabilitation pathways from the Centre for Sustainable Delivery. We will shortly start work on the national cancer referral pathways, first version due for release via RDS around end of June 2025.
  • HIS Quality of Care Review toolkit – currently in final stages of quality assurance.

 

The RDS team and other information scientists in HIS have also been producing evidence summaries for the Scottish Government Realistic Medicine team, to inform development of national guidance around Procedures of Limited Clinical Value. This guidance will in due course be translated into an RDS toolkit.

 

7. Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

  • Friday 28th February 12-1 pm
  • Tuesday 11th March 4-5 pm

 

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

 

To invite colleagues to sign up to receive this newsletter, please signpost them to the registration form  - also available in End-user and Provider sections of the RDS Learning and Support area.   If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot  If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

 

Right Decision Service team

Healthcare Improvement Scotland

 

 

First Afebrile Seizure Management, Emergency Department, Paediatrics (130)

Objectives

Guidance on the assessment, investigation and management of children with their first afebrile seizure.

Scope

Who is afebrile?

Temp below 38 degrees

If history and examination are suggestive of febrile seizure, the patient should be treated as such even if temp below 38 degrees

Are they still fitting? Have obvious neurological deficit/abnormality?

This guideline is aimed at those children who have fully recovered at time of presentation to ED. If still fitting, follow APLS guidelines on management of seizures. If depressed level of consciousness follow standard ABC approach

TEST BLOOD SUGAR (NEAR PATIENT TESTING) IN ANY CHILD WHO IS FITTING OR WHO HAS A REDUCED LEVEL OF CONSCIOUSNESS AT TIME OF PRESENTATION

For further information see “The management of a child with a decreased conscious level” in RHSC Emergency Medicine Clinical Guidelines.

SEEK SENIOR INVOLVEMENT IN PROLONGED SEIZURE AND THOSE WHO DO NOT RECOVER FULLY

Audience

Medical and nursing staff working in the Emergency Department, Clinical Decisions Unit and acute admissions unit.

November 2023: This guidance is currently under review as it has gone beyond the standard review date. It reflects best practice at the time of authorship / last review and remains safe for use. If there are any concerns regarding the content then please consult with senior clinical staff to confirm.

 

A first seizure of any kind is frightening to those who witness it. Parents have often thought that their child was going to die, and this anxiety must be understood, and if appropriate, allayed. The child may appear absolutely well by the time they arrive in the department.

TEST BLOOD SUGAR (NEAR PATIENT TESTING) IN ANY CHILD WHO IS FITTING OR WHO HAS A REDUCED LEVEL OF CONSCIOUSNESS AT TIME OF PRESENTATION

For further information see “The management of a child with a decreased conscious level” in RHC Emergency Medicine Clinical Guidelines.

SEEK SENIOR INVOLVEMENT IN PROLONGED SEIZURE AND THOSE WHO DO NOT RECOVER FULLY.

Differential diagnosis of first seizure

In a significant proportion of children presenting with a first afebrile seizure no diagnosis is found.

Differential diagnoses

1st presentation epilepsy

Acute symptomatic seizure i.e. related to:

  • Intracranial infection
  • Ingestion
  • Trauma
  • Tumour
  • Intracranial haemorrhage
  • Hypertension
  • Hydrocephalus
  • Metabolic (low glucose/ calcium/sodium etc)

In children under 3/12 in addition to the above the following diagnoses are considered-

  • Hypoxic Ischaemic Encephalopathy (from birth)
  • congenital infection
  • Fifth day fits
  • Drug Withdrawal
  • Pyridoxine dependancy

Other important differentials

Convulsive syncope:

  • Reflex anoxic seizures
  • Vasovagal seizure
  • Arrythmias e.g. long QT syndrome
  • Suffocation
  • Psychogenic seizures

History

  • Due to the anxiety attending seizure activity accurate timescales can be difficult to ascertain. It is useful to have a parent re-live the event that they witnessed, talking through in real time what they saw. This tends to give a more accurate reflection of timings.
  • What was the child doing, what happened just before the seizure started?
  • Were there any symptoms suggestive of aura? If so, what were they?
  • What was the sequence and timing of events?
  • Seizure onset and offset? Gradual or sudden?
  • What was the child like after the seizure and for how long?
  • Was there:
    • Awareness during event?
    • Unresponsiveness?
    • Staring?
    • Open or closed eyes?
    • Eyelid flutter?
    • Eyeball jerking or deviation?
    • Facial twitching?
    • Body stiffness?
    • Chaotic jerking of limbs?
    • Rhythmic jerking of limbs?
    • Pallor or cyanosis?
    • Respiratory effort?
  • Any relevant family history of seizures?

Record a detailed chronological history including any focal signs +/- secondary generalised seizure.

Examination

Ensure full neurological examination including : -

  • level of consciousness
  • gait/ cerebellar signs
  • fundoscopy if possible

Investigation

  • All children should have their blood pressure checked as part of their routine examination, in this case to exclude systemic hypertension as a rare but important cause of a seizure.

  • ECG: children with convulsive seizures may have syncope, including cardiogenic syncope, such as prolonged QT syndrome. ECG with calculation of QTc interval should be calculated on all children presenting with convulsive seizure.

Indications for admission and further investigation

  • Age < 1year
  • GCS < 15 one hour after seizure
  • Signs of raised intracranial pressure, papilloedema, tense fontanelle.
  • Meningism
  • Signs of respiratory aspiration
  • Complex seizure, i.e. prolonged (>15mins), focal or recurrent
  • Parents feeling unhappy to take child home following a full discussion.

Indications for discharge

  • In a fully recovered child who you are planning to discharge home. It is not necessary to routinely check a full blood count, urea and electrolytes, calcium or magnesium following a first afebrile seizure or a recurrent seizure, unless history or examination features suggest otherwise.

  • If child completely recovered with normal BP and ECG they may be discharged home after parental counselling.

Follow Up

  • When counseling parents it is useful to give some indication about the number of children who suffer from a single seizure. Around 1% of children will have an afebrile seizure by the age of 16 and about 50% of those that do will have a recurrence.

1st Seizure clinic referral guidelines

1st Seizure clinic referral guidelines flowchart

  • All children who have had a first afebrile seizure should be referred to General Paediatrics as per 1st seizure clinic referral guide.  Please circle General Paediatrics area on the referral appointment sheet (pink sheet) – no dictated letter required for this patient cohort but all clinical details should be completed on the ‘Paroxysmal Events Proforma’.

  • All children being discharged from the ED should be given advice on what to do in the event of a further seizure, including indications for calling ambulance / return to ED. Please provide the ‘Patient Information after a possible seizure’ leaflet. 

 

Calculating the corrected QT interval

Here's how to calculate the QTc using Bazett's formula:

  • Measure the QT interval, choosing a lead in which the T wave is clearly defined. Count the number of small boxes between the beginning of the Q wave and the end of the T wave and multiply by 0.04 for the time in seconds. Write this number down.
  • Don't include U waves (discrete waves that appear after the T wave has returned to baseline) as part of the QT interval.
  • Measure the R-R interval by counting the number of small boxes between the R wave of the complex you measured the QT time on, and the preceding R wave. Multiply by 0.04 and record the number in seconds.
  • Enter the measurement of the R-R interval into your calculator and press the square root button. Write this number down.
  • Divide the QT interval by the square root of the R-R interval to obtain the QTc.
  • NORMAL QTc <0.44. If the child has a longer QTc than this discuss with senior/cardiology

Editorial Information

Last reviewed: 23/10/2018

Next review date: 31/10/2024

Author(s): S Foster, V Choudhery.

Version: 3

Approved By: Clinical Effectiveness

Reviewer name(s): ED Guidelines Group.

Document Id: 130

References

SIGN 81: Diagnoses and Management of Epilepsies in Children and Young Adults.(2005) [WITHDRAWN]

NICE CG137: Epilepsies: diagnosis & management. (2016)

Paediatric Accident and Emergency Research Group: Seizure - An evidence based guideline for the management of children presenting post seizure (2004)