First seizure and seizure mimics — branching viva

Stem 1 — Eighteen-month-old with a febrile convulsion (5 minutes)

An eighteen-month-old boy is brought to the emergency department after a three-minute generalised tonic-clonic seizure at home. He has now stopped convulsing, is alert and smiling, and has a temperature of 39.2 degrees Celsius with an upper respiratory tract infection. He is previously well and developmentally normal. [8]

Branch A (examiner): Classify this febrile seizure and state which investigations, if any, are required for a child who has recovered like this. [8]

Branch B (examiner): The examiner now tells you the seizure lasted twenty minutes, was focal in the right arm, and the child is still drowsy. How does each feature change your classification and your management, and what is your next investigation? [12]

Branch C (examiner): The examiner asks you to counsel the parents on the risk of recurrence of febrile seizures and the risk of later epilepsy, and to give first-aid advice for the next febrile illness. [8]

Stem 2 — Nine-year-old with a first unprovoked seizure (5 minutes)

A nine-year-old girl is referred after a five-minute generalised tonic-clonic seizure witnessed at home, preceded by a brief odd smell. She is now back to baseline with a normal examination. There is no family history of epilepsy. [4]

Branch A (examiner): How do you classify this event by the 2017 ILAE scheme, and which investigation is the highest yield? [1] [6]

Branch B (examiner): Her electroencephalogram shows focal epileptiform activity in the left temporal region. How does this change her recurrence risk, and does it meet the definition of epilepsy? [2] [7]

Branch C (examiner): The parents ask whether she should start an antiseizure medication today. Outline your shared decision-making, the evidence on early treatment, and the safety-netting you provide if you advise waiting. [5] [7]

Stem 3 — Fourteen-year-old still convulsing at fifteen minutes (5 minutes)

A fourteen-year-old boy is brought to the resuscitation bay still convulsing. The convulsion began fifteen minutes ago and has not stopped. Intravenous access has not yet been obtained. [3]

Branch A (examiner): What is the diagnosis, and what is your immediate sequence of actions including the airway, the bedside blood test you must not omit, and the drug you give first? [3]

Branch B (examiner): Intravenous access has now been obtained and the first-line drug has been given without effect. Name your second-line agent, the dose, and an alternative. [11]

Branch C (examiner): The convulsion stops after the second-line agent. Outline how you would now search for the cause and counsel the family on what just happened. [3] [7]