childhood seizures and epilepsy for medical students

transcript

By Dr. Hussein Abdeldayem, MD Head & Professor of Pediatric Neurology Unit Faculty of medicine, Alex University

Childhood Seizures in ER :Management

• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation

ER/Seizures

• Seizure in children is one of the most anxiety-provoking conditions for parents and a coon reason for �emergency department visits, especially if the seizure is of new-onset or the child is not on anti-epileptic medication

• Anti-epileptic drugs should not be routinely initiated in the emergency department in children whose seizures have resolved

ER/Seizures (cont.)

Seizure ?

Epilepsy ?

Seizure : the involuntary clinical manifestation (S &/or S)

due to an abnormal and excessive excitation and synchronization of a population of cortical neurons

Epilepsy

Number ??? Time onset??

? FC, ? tetany

More than oneMore than one

More than one day apartMore than one day apart

unprovocativeunprovocative

EPILEPSY

Seizure is an Seizure is an ACUTE ACUTE ManifestationManifestation

Epilepsy is a Epilepsy is a Chronic Chronic DISEASEDISEASE

Is it Seizure?

How do u treat acute seizure?

What is the type of seizure?

PATHOGENESIS OF SEIZURES

Mechanisms of Seizures

• Defective balance between excitatory and inhibitory neurotransmission

+VE -VE

Mechanisms of Seizures

• Defective balance between excitatory and inhibitory neurotransmission

classification

• Aetiology• CP• EEG

EPILEPSYAetiology

• Idiopathic

• Symptomatic (Acquired)

• cryptogenic

• Genetic

• Structural (acquired)*

• Unknown

* More in neonates and infancts

1985 2010

Aetiology # Age

• Before age 2: Developmental defects, birth injuries, CNS infections and metabolic disorders

• Ages 2 to 14: Idiopathic (genetic) seizure* disorders

• Adults: Cerebral trauma, withdrawal, tumors, strokes, and unknown cause (in 50%)

• The elderly: Tumors and strokes

genetic GTCChildhood Absence

General ActivityGeneral Activity

Focal ActivityFocal Activity

2-Classification according to EEG findings2-Classification according to EEG findings

Classification according to EEG findings

GeneralizedGeneralized FocalFocal

Both Cerebral Hemispheres

Only a part of a hemisphere

Loss of Consciousness No loss of consciousness

Treated by Valproate Treated by Carbamazipine

MRIMRI

Focal withFocal with 2ry G2ry G

Pediatric SeizuresSeizure Type Classification

3- Clinically (ILAE 1981)

GENERALIZED

1- Involves both cerebral hemispheres

2- Loss consciousness

2- EEG: generalized

3- no aura

FOCAL (PARTIAL)

1- involve one

hemisphere

2- NO Loss of consciousness

3- EEG: focal activity

4- ± aura

Partial (focal) with secondary generalizationPartial (focal) with

secondary generalization

± MRI

ASKASKMRIMRI

Generalized SeizuresGeneralized Seizures

Tonic-clonic

Which type of seizure is this ?

Clonic

Generalize Spike Wave Discharge

Generalized Seizures

Absence

VPA, ETX, LMTVPA, ETX, LMT

Absence seizures and EEG

EEG: Absence Seizure

EEG: classic 3/sec spike-and-wave especially with HV

Myoclonic

Atonic

Myoclonic

Atonic

Absence

TonicClonic

Tonic-clonic

VALPROIC ACID

(focal)(focal)

simplesimple

MotorMotor

EEG: Simple focal Seizure

EEG: Focal changes

Sensory

autonomic

psychic

Simple Partial (Focal) Seizures

Partial (Focal)

Complex partial

Complex Partial Seizure.flv

ComplexSimple

Partial (Focal) Seizures

2ry Generalization

Carbamazepine

Febrile Convulsions FCDefinition

• Age : between 6 months and <6 years of age

• with fever > 38 ํC ( rectal temperature)

• but without evidence of intracranial infection and no history of prior afebrile convulsion

Precipitating factors:

Precipitating factors: 1.1. Body Body Temperature:Temperature:

• Temperature ≥ 38 〬 C

• FC occur during 1st 24 hrs of the febrile illness

• Depends on the rapidity of the rise rather than the temperature itself

2. Infections & FC:

• VIRAL :VIRAL : UTRI, otitis media, roseola infantum

• Bacterial: gastoeneritis, pneumonia, UTI

• Post-Vaccinational: pertussis & measles vaccination

3. Genetic Factors:• Positive family history for febrile seizures.

• In most cases the disorder appears polygenic. I

n some families the disorder is inherited as an autosomal dominant traitautosomal dominant trait,

• Multiple single genes Multiple single genes causing the disorder have been identified, FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes:

• 8q13-q21

• 19p13.3

• 2q24

• 5q14-q15

• 6q22-24

• 18p11.2• 21q22.

Classification of FC

• Simple (typical) FC

• Complex (atypical) FC

Simple FC complex FC

• Constitute 80-85% of FCs

1- generalized tonic-clonic motor activity

2- less than 15 minutes with rapid return of consciousness.

3- not recurring more than once within 24hrs

4-no postictal neurological abnormalities

5- normal CNS child

• Constitute 15 – 20% of FCs

1-focal seizure manifestations

2-prolonged seizure activity exceeding 15 minutes

3- recurring more than once within 24 hrs

4- postictal neurological abnormalities

5- abn CNS : as CP

No EEGNO AEDNo EEGNO AED

EEGAED

Infantile Spasms

S Zaher IS.3gp

VPACZPVGB

EEG finding:hypsarrhythmias

NEONATAL CONVULSIONSSubtle

2- eye1- APNEA

3- oral

4- UL 5- LL

History (9)

• First• Last• Frequency

• Aura • Ictal • Postictal

• duration• Investigation• Treatment

Practical Points

DURATION OF TREATMENT

2 years from last attack Withdraw over 3 months

VPA GENERALIZED FITS

PARTIAL FITS

GENERALIZED FITS

PARTIAL FITS

Depakine (Valproate)

• 20 – 60 mg/kg/d• Twice*• FormsOral with dropperOral with spoon200 mg tablets500 mg chrono tablets• Follow up of:Serum drug level (peak)Serum drug level (trough)SGOT, SGPT, PT

Tegretol (Carbamazepine)

• 10 – 20 mg/kg/d*• Twice• Forms

Oral (100 mg/5ml)

200 mg tablets

200 mg CR tablets

400 mg CR tablets• Follow up of:

Serum drug level (peak)

Serum drug level (trough)

Blood CBC

Question for ALL

• For my pediatric epileptic patients, well controlled seizures are mostly through:

A- Monotherapy

B Polytherapy (2 drugs)

C- Polytherapy (3 or more drugs)

D- Other methods (?)

Seizures in E DSeizures in E D

• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation

• prolonged seizures may result in neuronal injury, cell death, or both, and this becomes most pronounced after half hour or more of continuous seizure activity

• the earlier the therapeutic intervention, the

more likely one can terminate the seizure

Status EpilepticusStatus Epilepticus

• 30*** minutes of continuous seizure without regaining consciousness

• Two or more Seizures with Failure to regain consciousness Between Seizures (serial status)

Practical SE

• If a seizure continues for more than 5 minutes or

• the patient has 2 or more generalized tonic-clonic seizures within 1 hour,

Aggressive management is warranted asthese patients progress rapidly to status epilepticus

Practical Status epilepticus

Generalized convulsive status epilepticus involves at least one of the following:

• Tonic-clonic seizure activity lasting > 5 to 10 min

• ≥ 2 seizures between which patients do not fully regain consciousness

Stay calm and manage effectively

Handling of the active

seizure

Never restrain the child or place anything in the mouth

Treatment

• ABCDs

• Specific treatment*

• Airway• Breathing• Circulation• Drugs

*Initial studies include glucose, serum chemistries (most importantlysodium, magnesium, calcium, phosphate, BUN), arterial blood gas, AED levels (if applicable), CBC

Lorazepam (ativan) 0.1 mg/kg

Diazepam 0.3 mg/kg*

PR diazepam 0.5 mg/kg

• In infants less than 24 mo of age, intravenous pyridoxine (100–200 mg) should be considered.

Rectal Diazepam*

• The absorption of oral diazepam is slow (1-2 hours) and variable.

• Intramuscular diazepam has similar absorption problems, is painful and may cause muscle necrosis.

• Suppositories have slow and variable absorption rates and are not recommended in an emergency.

Rectal administration of the intravenous form of diazepam

Rectal Diazepam*

• Intravenous and rectal diazepam both stop seizures in more than 80% of cases within 10-15 minutes

Less Resp Depression

Less BP Depression

Less CNS Depression

Prolonged action

Rectal Diazepam

• Use IV ampoules (10mg/2ml) or gel• Use Insulin syringes*• Rectal administration (use lubricant)

Dose: 0.5 MG/KG max: 10 mg

Lubrication

Diazepam adsorbs to plastic and thus needs to be stored in glass

The following statements are either true or false

• Rectal diazepam is the treatment of choice for status epilepticus.

• 2. Oil in water emulsions of injectable diazepam are inappropriate for rectal administration.

Timed treatment

• 0 – 5 min ABCD*• 5 -10 min BZD IV x2• 10-20 min DPH or PB IV• 20-30 min PB or DPH IV• >30 min midazolam IV continuous

infusion**• 40–60 min ICU, anesthesia, EEG

Give the Diagnosis

Seizure pretenders

• • Paroxysmal nonepileptic disorders that

may be mistaken for seizures include syncope, breath holding spells, sleep disorders, migraine headaches, apparent life threatening events (ALTE), and pseudoseizures

Thank youThank you

Case (cont.)

• You are called to the bedside and after 5 minutes, these movements have not stopped.

• Options for your next course of action are:

1- continue to wait for the spell to subside

2- administration of IV diazepam

3- administration of IV phenytoin

4- administration of IV phenobarbitone

childhood seizures and epilepsy for medical students

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