Seizures and epilepsies in children
Nebal Waill Pediatric neurology department Children Welfare Teaching HospitalTerminology & Definition
Seizure : a sudden alteration in behavior , awareness, motor movement , body posture, autonomic function and/or sensory or psychic perception from both physiological (epileptic ,chemical, anoxic , etc) and nonphysiological (psychological ) causes, which may be paroxysmal and stereotyped. Epilepsy :the tendency to have recurrent, unprovoked seizures caused by physiologically abnormal brain electrical activity produced by idiopathic or diverse brain pathologies.Convulsion: a sudden rhythmical motor behavior , body posture, or alteration in body tone from diverse physiological (epileptic, hypnic, chemical, anoxic , etc) and nonphysiological (psychological) causes, which may be paroxysmal and stereotyped.
tonic : characterized by increased tone or rigidity. Atonic seizure : are characterized by flaccidity or lack of movement during a convulsion
Clonic seizure : consist of rhythmic muscle contraction and relaxation
Myoclonic seizure : shock like contraction of a muscle.Seizure categories
Focal seizure ( previously known as partial or focal )Generalized seizures ( convulsive or non convulsive )
Simple ( consciousness not impaired )
Complex ( with impairment of consciousness )
Focal seizures with secondary generalization
Absence seizure Atypical absence seizures Myoclonic seizures Clonic seizures Tonic seizures Tonic – clonic seizures Atonic seizures Unclassified epileptic seizures
Focal seizures
Simple
With motor symptoms With somatosensory or special sensory symptoms With autonomic symptoms With psychic symptoms
Complex
Begin as simple focal and progressing to impairment of consciousness With no other features With features as in A 1-4 With automatisms
With impairment of consciousness at onset With no other features With features as in A 1-4 With automatisms
Focal seizures secondarily generalized
Focal arise in specific loci in the cortex which carry with them identifiable signatures either subjective or observational Generalized seizure involves large volumes of brain from the outset and are usually bilateral in their initial manifestations and associated with early impairment of consciousness Accordingly many different seizures in the immature would be left unclassified
Videos
Evaluation of seizureDetermine whether it has a focal onset or is generalized Describe the motor type Document the duration of the seizure and state of consciousness ( retained or impaired ) Determine whether an aura proceeded the convulsion & the most common aura experienced in children consists of epigastric discomfort or pain and a feeling of fear Posture of patients Presence and distribution of cyanosis Vocalization Loss of sphincter control ( particularly the urinary bladder ) Post-ictal state ( sleep, headache, hemiparesis ) should be noted
Febrile convulsion
FC : seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures Conditions :Temperature : the key factor is the actual peak temperature , must be > 38.4 C˚Age : it’s age dependent , most common 6mo – 5 yr. Classification Simple Generalized Isolate Brief : Duration <15minComplex Focal Multiple ( > one in 24hr or febrile illness ) Prolonged : > 15min
Initial evaluation
LP: strongly considered <12 mo 12-18mo = need careful assessment > 18 mo = not necessary in absence of suspicious findings on Hx & PESkull X-ray of no value CT of limited benefit unless suspect trauma or ICP MRI not indicated EEG of limited value
Treatment
Stopping FS By diazepam and if persist protocol of SEEducation is key to empower the parents Keep child safe during seizure
Preventing epilepsy No evidence
Very general rule of thumb to treat epilepsy Generalized epilepsies and syndromes : Na ValproateFocal seizures +/- generalization : carbamazepine lamotrigine
Status epilepticusFunctionally a seizure lasting more than 30 (5, 10) minutes or recurrent seizures lasting more than 30 (5,10) minutes from which the patient does not regain consciousness
Precipitating Events
AED alteration : noncompliance Withdrawal Interaction toxicityInfections CNS Systemic
Toxins Alcohol Drugs Poisons Convulsive agents
Structural Trauma Ischemic stroke Hemorrhagic stroke Acute hydrocephalus
Hormonal change
Diagnostic procedures and medications
Emotional stress
Electrolytes imbalance
Sleep deprivation
Primary apnea
Cardiac arrhythmia
Progressive-degenerative disease
fever
Medical complications of SE
Tachycardia Bradycardia Cardiac arrhythmia Cardiac arrest Conduction distrubance Congsetive heart failure Hypertension Hypotension Altered respiratory pattern Pulmonary edema Pneumonia Oliguria Uremia RTA Lower nephron nephrosis Rhabdomyolysis MyoglobinuriaApnea Anoxia Hypoxia CO2 narcosis Intravascular coagulation Metabolic and respiratory acidosis Cerebral edema Excessive perspiration Dehydration Endocrine failure Altered pituitary function Elevated prolactin Elevated vasopressin Hyeperglycemia Hypoglycemia Increased plasma cortisol Autonomic dysfunction Fever
Treatment of status epilepticus
Transferred to ICU ABC Remove by gentle suction excessive oral secretion Properly fiting face mask attached to O2 Ambubag N/G i.v catherterBenzodiazepine : Diazepam Lorazepam midazolam
phenobarbitoneBenzodiazepine infusion: midazolam , diazepam , propofol
Phenytoin / phosphenytoin
Barbiturates coma : thiopental
Paraldehyde
GA: halothane , isoflurane
Physical and neurological examination Papilledema Ant. Fontanel Retinal hemorrhage Kussmaul breathing + dehydration Peculiar body odor Abnormal hair pigmentation Pupillary dilatation or constriction After control seizure take detailed history
Doses of drug used in SE
Diazepam 0.1-0.3mg/kg at rate not more than 2mg/min Diazepam repeated for max. of 3 doses.Phenytoin
If the convulsive activity cease after diazepam or lorazepam therapy or if seizures persistPhenytoin : 15-30mg/kg i.v infusion rate 1mg/kg/minIf seizure don’t recur maintenance[3-9mg/kg/day ч 2 began 12-24hr