SEIZURE IN CHILDREN

BY

Shikha.S.A

2nd

Year MSc (N)

Definition

A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioural manifestations.

Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.

ETIOLOGY

Low oxygen during birth

Head injuries that occur during birth or from accidents during youth or adulthood

Brain tumours

Genetic conditions that result in brain injury, such as tuberous sclerosis

Infections such as meningitis or encephalitis

Stroke or any other type of damage to the brain

Abnormal levels of substances such as sodium or blood sugar

RISK FACTORS

Age - The onset of epilepsy is most common during early childhood and after age 60, but

the condition can occur at any age.

Family history

Head injuries - Head injuries are responsible for some cases of epilepsy.

Stroke and other vascular diseases - Stroke and other blood vessel (vascular) diseases

can lead to brain damage that may trigger epilepsy.

Brain infections - Infections such as meningitis, which causes inflammation in the brain or

spinal cord, can increase the risk.

Seizures in childhood - High fevers in childhood can sometimes be associated with

seizures.

CLASSIFICATION OF SEIZURE

Seizure

Generalized

Partial

Tonic-Clonic

Absence

Myoclonic

Clonic

Tonic

Atonic

Simple partial

Complex partial

Generalized seizure

Generalized Seizures(Produced by the entire brain)

Symptoms

1. "Grand Mal" or Generalized tonic-clonic Unconsciousness, convulsions, muscle rigidity

2. Absence Brief loss of consciousness

3. Myoclonic Sporadic (isolated), jerking movements

4. Clonic Repetitive, jerking movements

5. Tonic Muscle stiffness, rigidity

6. Atonic Loss of muscle tone

Partial seizure

Partial Seizures

(Produced by a small area of the brain)

Symptoms

1. Simple(awareness is retained)

a. Simple Motor

b. Simple Sensory

c. Simple Psychological

a. Jerking, muscle rigidity, spasms, head-turning

b. Unusual sensations affecting either the vision,

hearing, smell taste, or touch

c. Memory or emotional disturbances

2. Complex(Impairment of awareness)

Automatisms such as lip smacking, chewing,

fidgeting, walking and other repetitive, involuntary

but coordinated movements

3. Partial seizure with secondary generalization

Symptoms that are initially associated with a

preservation of consciousness that then evolves into

a loss of consciousness and convulsions.

STATUS EPILEPTICUS (SE)

Is a life-threatening neurologic disorder defined as 30 minutes or more of a continuous seizure, or two or more discrete seizures without complete recovery of consciousness between seizures.

Two common forms of SE are generalized convulsive SE, involving prolonged seizures, and nonconvulsive SE, involving changes in behaviour, memory, affect, or level of consciousness.

Cont.…….

Treatment must begin immediately after diagnosis, because SE of long duration is associated with an increase in neurologic morbidity and seizures may become less responsive to medication with time.

Begin treatment with supportive care; ensuring sufficient oxygenation is essential. If seizures do not terminate on their own, administer antiepileptic medication

Causes of SE

Fever

Pre-existing epilepsy

Genetic predisposition

Cerebral palsy

Stroke or brain insults, such as prior or acute head trauma, CNS infection, and cerebrovascular disease including arterial ischemic stroke or intracranial haemorrhage

Progressive neurologic disorders such as brain tumour or neurodegenerative disease

Hypoxic-ischemic encephalopathy

Metabolic and electrolyte disturbances (e.g., hypoglycaemia, hyponatremia, hypernatremia, hypercalcemia)

Drug intoxication (alcohol, cocaine, theophylline, tricyclic antidepressants, amphetamines, insulin)

Acute withdrawal of AEDs

Progressive neurologic disorders such as brain tumours or neurodegenerative diseases

IMMEDIATE CARE

Verify diagnosis

Obtain brief history focusing on known convulsive disorders, medication usage, and any recent medication changes, drug allergies, alcohol or substance misuse, recent acute illness, chronic disease, or previous brain injury.

Initiate supportive care

Assess and secure airway and oxygenation; insert nasal airway or intubate if necessary. Administer 100% oxygen

Monitor pulse, blood pressure, respiration, and temperature

Secure intravenous access in large vein

CONT…..

Send blood for complete blood count, serum electrolytes, calcium, magnesium, blood urea nitrogen, liver function tests, glucose, and antiepileptic drug levels, clotting studies, and toxic drug screen

Check arterial blood gases

Begin isotonic saline at a low infusion rate

Give 50 mL of 50% glucose intravenously if hypoglycemia is suspected, or prophylactically if glucose levels cannot be determined

SIGNS AND SYMPTOMS

Generalized absence seizures

Staring

The child suddenly stops what she is doing

A few seconds of unresponsiveness (usually less than 10 seconds, but it can be up to 20 seconds) that can be confused with daydreaming

No response when you touch your child

The child is alert immediately after the seizure

The child may have many seizures per day

Repetitive blinking

Eyes rolling up

Head bobbing

Generalized myoclonic seizures

One or many brief jerks, which may involve the whole body or a single arm or leg

In juvenile myoclonic epilepsy, these jerks often occur upon waking

The child remains conscious

Generalized atonic seizures

Sudden loss of muscle tone

The child goes limp and falls straight to the ground

The child remains conscious or has a brief loss of consciousness

Eyelids droop, head nods

Jerking

The seizure usually lasts less than 15 seconds, although some may last several minutes

The child quickly becomes conscious and alert again after the seizure

Generalized tonic-clonic seizures

The child cries out or groans loudly

The child loses consciousness and falls down

Heart rate and blood pressure rise

Sweating

Tremor

In the tonic phase, the child is rigid, her teeth clench, her lips may turn blue because blood is being sent to protect her internal organs, and saliva or foam may drip from her mouth; she may appear to stop breathing because her muscles, including her breathing muscles, are stiff

Cont.........

In the clonic phase, the child resumes shallow breathing; her arms and legs jerk quickly and rhythmically; her pupils contract and dilate

At the end of the clonic phase, the child relaxes and may lose control of her bowel or bladder

Following the seizure, the child regains consciousness slowly and may appear drowsy, confused, anxious, or depressed.

Simple partial seizures

Motor seizures

Brief muscle contractions (twitching, jerking, or stiffening), often beginning in the face, finger, or toe on one side of the body.

Twitching or jerking spreads to other parts of the body on the same side near the initial site.

Other motor seizures may involve movement of the eye and head.

The seizure begins the same way each time.

The child remains conscious.

Cont……..

Sensory seizures

Seeing something that is not there, such as shapes or flashing lights, or seeing something as larger or smaller than usual

Hearing or smelling something that is not there

Feeling of pins and needles or numbness in part of the body

The child remains conscious

Cont…….. Autonomic seizures

Changes in heart rate

Changes in breathing

Sweating

Goose bumps

Flushing or pallor

The child remains conscious

Strange or unpleasant sensation in the stomach, chest, or head

Changes in heart rate

Changes in breathing

Sweating

Goose bumps

Flushing or pallor

The child remains conscious

Complex partial seizures

Warning sign such as a feeling of fear or nausea

Loss of awareness

Confusion after the seizure

Loss of memory about events just before or after the seizure

Loss of awareness

Blank stare

Walking or running

Automatisms such as mouth movements, picking at air or clothing, repeating words or phrases

Confusion after the seizure

Loss of memory about events just before or after the seizure

DIAGNOSIS

Blood tests (such as blood sugar, complete blood count, electrolytes and liver and kidney function tests)

Electroencephalography (EEG), a test that records electrical activity in the child’s brain

Brain imaging tests including CT, MRI and PET scans to look for any scar tissue, tumors or brain malformations that may be causing seizures

Spinal tap (lumbar puncture) to see if there is an infection or other problem

PET /SPECT-Radioisotopes, radioactive materials injected into the vein and traced with either PET or SPECT with to detect areas of brain epileptic foci.

TREATMENT

Principles of Treatment

Treatment should be started with a single conventional AED (monotherapy).

The dose should be slowly built up until seizure control is achieved or side effects occur.

If the initial treatment is ineffective or poorly tolerated then monotherapyusing another AED can be tried

The dose of the second drug is slowly increased until adequate or maximum tolerated dose is reached.

The first drug is then tapered off slowly.

Combination therapy (polytherapy or adjunctive or “add-on “therapy) can be considered when two attempts at monotherapy with AEDs have not resulted in seizure freedom.

CONT……..

Phenytoin (PHT), phenobarbitone (PB), carbamazepine (CBZ), oxcarbazepine (OXC) and valproate (VPA) are usually called “conventional” or “first-line drugs”.

The other AEDs are called “new "or “second-line drugs”.

It is preferable to use a conventional AED as the initial drug since those are less expensive and the side effects with long-term use are well-known.

SURGERY

Epilepsy surgery may be resective or nonresective.

Resective surgery includes lesionectomy (resection of the lesion and the surrounding epileptogenic area), amygdalohippocampectomy with or without temporal lobe resection, multilobar resection and hemispherectomy.

Non resective surgery includes multiple subpial transections corpus colostomy and vagus nerve stimulation (VNS)

Ketogenic Diet in Epilepsy

High fat and low protein/carbohydrate diet given with/without a restricted fluid intake to maintain ketosis.

It can be used in all children above the age of 1 year with drug-resistant epilepsy.

Adverse effects include GI disturbances, acidosis, increased susceptibility to infections, drowsiness, weight loss, nutritional deficiencies and rarely, renal calculi and pancreatitis.

In failures it should be discontinued after in 3-6 months.

In responders, it should be continued for 2-3 year.

IN TONIC-CLONIC SEIZURE

DURING SEIZURE

Remain calm

Time the seizure episode

If child is standing or seated, ease the child down to the floor

Place pillow/ folded blanket below the child’s head.

Loosen restrictive clothing

Remove eye glasses

Clear area of any hazards or hard object

Allow seizure to end without any interference

If vomiting occurs, turn the head of the child to one side.

Do not attempt to restrain the child.

Do not put anything in child’s mouth.

Do not give any fluids or liquids.

After seizure

Time the post ictal period

Check the breathing. Check the position of head and tongue. Reposition if head is hyperextended

If child is not breathing give rescue breathing and call for emergency medical service.

Keep child on side

Remain with child

Do not give food or liquid until fully alert and swallowing reflex has returned.

Check head and body for possible injury

Check inside of mouth to see if tongue or lips have been bitten.

In complex partial seizure

DURING THE SEIZURE

Do not restrain

Remove harmful object from area

Redirect to safe area

Do not agitate; instead talk in calm reassuring manner

Do not expect child to follow instruction

Watch to see if seizure generalize.

PROGNOSIS

Prognosis for children with seizure depend on the etiology, type of seizure, age of onset, family and medical history. Risk factors associated with recurrence of epilepsy include:

Adolescent age and older

Family history of epilepsy

Frequent seizure on antiepileptic medication

Multiple antiepileptic therapy

Abnormal EEG

Seizure result from past injury/ insult.

NURSING DIAGNOSIS

1. Risk for Injury related to uncontrolled seizure activity (balance disorder).

2 .Ineffective airway clearance related to blockage of the tongue, endotracheal tube, increased secretion of saliva.

3. Social isolation related to low-self against the disease state, and the bad stigma against epilepsy in the community.

4. Ineffective breathing pattern related to dyspnoea and apnoea.

5. Activity intolerance related to decreased cardiac output, tachycardia.

6. Impaired sensory perception related to disturbances in nerve sensory organs of perception.

7. Anxiety related to lack of knowledge about the disease.

8. Risk for Ineffective cerebral Tissue Perfusion related to decreased oxygen supply to the brain.