Date post: | 22-Jan-2018 |
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To enable you :
To identify the seizure
To identify the probable type
To initiate managing a child with seizure
To identify and manage Febrile seizures
To understand the stepwise management of status epilepticus and its significance
Define: Seizures / Convulsions / Fits:
Sudden, excessive discharge of neurons resulting in involuntary motor, sensory or autonomic disturbances
with or without alteration in sensorium
USA statistics: 5% of children are at risk of getting at least once in a life time
Focal: Neurons in one hemisphere.(conscious +): Focal insult (tumour)
Generalized: Neurons of both hemispheres (conscious is lost) (Generalized insult to both hemispheres – hypoxia)
Febrile seizures: Seizures due to fever of extra-cranial origin
Acute symptomatic seizures: secondary to an acute problem (Electrolyte, Glucose, Encephalitis & Meningitis), usually GTC
Unprovoked seizures: No obvious reason
Epilepsy: >2 unprovoked seizures, >24 hours apart
Epileptic syndrome: 1 or more specific seizure types, specific age of onset & specific prognosis.
Idiopathic epilepsy: No underlying disorder; presumably genetic
Symptomatic epilepsy: Underlying brain disorder (epilepsy secondary to Tuberous sclerosis)
Cryptogenic epilepsy (presumed symptomatic epilepsy): Presumed underlying brain disorder but the cause is not known
Epileptic encephalopathy: Severe EEG abnormality, Cognitive impairment
Excitatory Amino acid
Injury to Neurons
Death of neurons
Excessive discharge concerned activity
Motor cortex jerking of limbs
Electrodes
Electrical activity of brain
Waveforms: theta, delta, alpha and beta
Abnormalities of wave form: spike & slow waves
Epileptiform activity may be enhanced by activation procedures:hyperventilation, photic stimulation & sleep deprivation
Use: to diagnose seizures; to classify seizures
FOCAL
CONSCIOUSNESS IS MAINTAINED
a. Focal seizures with retained consciousness (Simple partial)
b. Focal dyscongnitive (Complex partial)
c. Partial seizures with secondary generalization
GENERALIZED
CONSCIOUSNESS IS IMPAIRED
a. Petit mal (Absence)
b. Grandmal
c. Myolconic
Rare & complex seizure types and syndromes are not included in this classification
Aura: Sensory experiences (depend on the location)
Visual (flashing lights/seeing colours)
Somato-sensory (tingling)
Olfactory, auditory, vestibular
Experiential (dejavu)
Post-ictal period:
Sleep, vomit, automatism
1. Simple Partial (Focal S with retained consciousness):
Motor: tonic/ clonic – particular limb
Sensory: abnormal sensation of a particular limb or part of limb
Autonomic: excessive sweating, palpitation
Versive: head turning & conjugate deviation of eyes
May verbalize during the seizures - 10-20 sec only
No post-ictal phenomenon
EEG: spikes or sharp waves
2. Focal dysconjugative seizures (Complex Partial) :
1/3 has Aura: Epigastric discomfort, fear
Act: brief blank stare or sudden cessation of activity; lasts for 1-2 m min.
2/ 3 has Automatism: usually, alimentary; lip smacking, repeated chewing , repeated swallowing; pulling at clothes, walking & running aimlessly
EEG: sharp waves or focal spikes and multi focal spikes
MRI: may show abnormalities over temporal regions
1. Petit mal or Typical Absence seizures:- (5-8 years)
Aura: Absent
Breathing: Hyperventilation for 3 min, could ppte. a seizure.
Seconds – each seizure lasts for seconds, but can have 100 such seizures in a day.
Eye lid flutter with brief blank stare or sudden cessation of activity, or upward rolling of eyes
No florid automatisms (if at all, simple automatisms like lip smacking)
Three Hz spike – slow – wave discharges – Typical in EEG
2. Grandmal seizures:-
Prodromal: hours to days- irritability; uneasiness
Aura: Minutes to seconds- Epigastric discomfort, fear
Tonic: 10-30 sec- Resp. muscle spasm: cry as the air is expelled –cyanosis may be +; consciousness is lost
Clonic: 1-5 min- jerking of all 4 limbs & face; may bite teeth; urine & fecal incontinence can occur
Post-ictal state: 30 min -2 hours: semicoma to deep sleep; may have headache / vomiting.
2. Grandmal seizures:
Age: 9-25 years
Usually within 2 hours after sleep.
Photic stimulation, sleeplessness & hypoglycemia can precipitate.
EEG: 2.5 to 4 Hz spike and wave activity enhanced by hyperventilation & photic stimulation
3. Myoclonic seizures:-
Brief, symmetric muscular contractions ( 1-2 seconds)
Loss of body tone –fall forward -cause injuries to the face and the mouth (if he is standing)
Several types
Prognosis may vary - very good to very bad.
Benign: Benign childhood epilepsy with centrotemporal spikesBenign epilepsy with occipital spikes
Serious: Temporal lobe epilepsy Landau-Kleffner epileptic aphasia syndromeRasmussen encephalitis (chronic encephalitis-intractable epilepsy
–progressive atrophy of cerebral hemisphere)
Type of myoclonic
epilepsies
Age Symptomatic/
Idiopathic
EEG Prognosis Drug
Early myoclonic
encephalopathy
Neona
te
Severe
Neurological
abnormalities
Suppression alternating
complex bursts of spike,
sharp & slow wave
Very poor;
early death
West syndrome
(Infantile
spasms) Flexor /
Extensor/ Mixed
3-8
mon
MR +;
70% HIE, NTD;
CNS infn.
30% crypto
Hypsarrythmia (high
voltage, slow, chaotic
background with
multifocal spikes)
Very poor;
5% may recover
Valproate,
ACTH,
Benzodiazepines
Vigabatrin
Benign
myoclonic
epilepsy of
infants
1-2yrs Normal .Normal Very good; stops
by 2 years of
age
No drug
Lennox-gestaut
syndrome triad:
developmental
delay, multiple
seizure types,
EEG)
3-5yrs MR,
Neurologically
abnormal:90%
Diffuse slow spike &
wave
Very poor; often
status epi for
days
Resistant to
many drugs.
ACTH tried.
Myoclonic
astatic
3-5yrs Normal in the
beginning
Irregular spike & wave
in sleep
50% better
Juvenile
myoclonic
epilepsy of Janz
(Janz syndrome)
8-
26yrs
Normal 4-6 Hz polyspike & slow
wave gen discharges
Better with drug Valproate
Life long
Landau Kleffner: Acquired aphasia with epilepsy syndrome
Aphasia +
Behavioural problems are common
Seizures: partial or generalized
EEG:
Prognosis: long term recovery of language function is not very good
Treatment: Valproic acid is the drug of choice
Duration, type of movements, aura, automatism, frequency
Associated illness: fever, loose stools, …
Sometimes, parents may overlook: absence, CPS
Precipitating events: less sleep, stress, television, menstruation
H/O Prenatal or perinatal insult
H/O Regression of mile stones
H/O Personality changes / ICT: Brain tumour
Inititial steps:
Shift child to a safer place (away from water, fire..)
Put him in left lateral position (to prevent aspiration, if V)
Roll a kerchief and keep between teeth, if possible
ABC
Airway: clear the secretions
Breathing: give O2 / bag and mask / intubation
Circulation: Pulse/ BP/ CFT: IVF
Emergency therapy: Stop the convulsions with fast acting Benzodiazepines..
Diazepam / Lorazepam/ Midazolam: Lora: Longer duration of action; (0.05 mg/kg)Midazolam: by any route: IM/Nasal/Buccal (0.1mg/kg)
Even 5 minutes after the 1st dose of Benzodiazepines, if convulsions do not stop:
Give 2nd dose of Benzodiazepines + Start long acting drugs IV (Phenytoin/PB)
At 10 min: 3rd dose of BenzodiazepinesAt 15 min: 4th dose of Benzodiazepines
Then plan Investigations
Blood sugar Serum electrolytes Serum calcium Smear for malaria CSF analysis CT scan / MRI EEG
If it is a symptomatic seizure, usually they may not require long term anticonvulsants.
Otherwise, give daily anticonvulsants until 2 years of seizure free interval
Anti- convulsants: which one to choose?
It depends on the type of the seizure
Age of the child (Valproate is avoided in < 2 yrs)
Sex of the child (Phenytoin avoided inadolescent females)
Pre-existing disease if any. (Jaundice)
Seizure types Drug of choice
Focal Carbamazepine
GTC Valproate / Phenytoin / Phenobarbitone
Absence Valproate / Ethosuximide
Myoclonic Valproate / clonazepam / clobazam
Drugs Not serious but common Serious
Phenytoin Gingival hyperplasia,
hirsuitism, ataxia
Stevens –Johnson syndrome
Liver damage
Phenobarb
itone
Disturbances is memory,
mood & sleep
Same as above
Carbamaz
epine
Weight gain, Nausea Stevens Johnson syndrome
Liver damage
Aplastic anemia
Valproic
acid
Weight gain, Menstrual
irregularities, alopecia
Liver damage
Pancreas damage
Benzodiaz
epines
Sedation Respiratory depression
In emergencies: loading dose: PB / PH: 20 mg
In non emergencies: maintenance dose is started
Small dose gradually increased (carbamazepine)
Steady blood level after 5 half-lifes (2-7 days) (PB: 2-4 wks)
Monotherapy-max. dose-start another-taper the first one
Monitored for side effects (Vit D: PB, Phenytoin; PH: good oral hygiene; rinsing the mouth after phenytoin)
Stopping: if child is seizure free > 2 years; gradually, even over 3 months
Prevalence: 3-4% in the community
Risk is more, if parents / siblings have FS (10-45%)
Genetical predisposition: Chromosomes 19, 9 & 5
Patho-physiology:
Rise in temp rise in excitatory postsynaptic potential convulsion
Rise in temp failure of Na-K pump at cellular level convulsion
Age: 6 months to 60 months
Within 24 hours of onset of fever
Usually occurs once only for one episode of fever
Lasts < 15 minutes; GTC in type
After 24 hours: No focal deficit
EEG: 2 wks after seizure (sleep & awake 20 min): normal
Those who do not satisfy any of the above criteria, ATYPICAL
Chance of relapse: 25-30% with every episode of fever
Recurrence risk is more:
First episode of seizures < 1 year
Family H/o Febrile seizures / epilepsy
Atypical febrile seizures
Risk of epilepsy:
Complex FS / Neuro developmental abnormalities
Risk of developing Status epilepticus: 5%
If child already had status, the risk of getting another status is more
1) Control of temp (Para & tepid sponging)
2) Intermittent Prophylaxis: Diazepam / Clobazam – 48 hours
3) Treat the cause for fever
4) If the child is throwing the seizures: ----
Definition:
Single or Multiple episodes of seizures, without regaining consciousness lasting for > 30 min; mostly generalized / can be partial
To be more practical:
Any child convulsing for > 5 min, should be considered as status (because, all self limited seizures usually stop in < 5 minutes)
Any child presenting to the casualty with active seizures should be considered as status only.
Why it is important?
Risk of cerebral edema, hypoxia, hyperthermia, hypoglycemia, vasomotor in-stability, vomiting & aspiration and respiratory depression
Risk of death / residual neurological sequelae
1/3: first seizure itself will present with status
1/3: occur in already diagnosed epilepsy patients
1/3: occur due to some acute insult
In India, the most common cause is febrile seizures
0 min: ABC; send blood for investigations (Blood glucose, serum electrolytes, BUN, Toxicology screen & serum anticonvulsants
levels)Give one dose of Benzodiazepine(Lora 0.1mg/kg; Mid 0.15mg/kg; Dia 0.3mg/kg)
+ Phenytoin : 20mg/kg @ 1mg/kg/min+ if CBG less, give dextrose 4 ml/kg
At 5 min: if seizures + : repeat BenzoAt 10 min: if seizures +: repeat BenoAt 15 min: if seizures + : repeat Benzo
At 20 min: if seizures + : (Refractory Status)add PB 5-10mg/kg @
1mg/kg/minrepeat
At 40 min: if seizures+ : midazolam infusion: 2-10mcg/kg/min consider sodium valproate infusion / ventilator support
Physical and neurological examination:LP & Antibiotics if meningitis suspected
Trauma with intracranial bleed:CT & Neuro surgeon’s opinion
Serum anti-convulsants levels