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    18.d Seizures

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    Samantha Lui
    Seizures are the most common pediatric neurological disorder, affecting 4-10% of children in their first 16 years. There are several types of seizures including generalized and partial seizures. Febrile seizures are the most common type in childhood. Status epilepticus is defined as continuous seizure activity lasting longer than 30 minutes. The management of seizures involves stabilizing ABCs, stopping the seizure with benzodiazepines or other anticonvulsants, and performing diagnostic tests based on the history and physical exam findings. Febrile seizures are usually benign but the cause of fever needs to be identified.

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    18.d Seizures

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    Samantha Lui
    29 views6 pages
    Seizures are the most common pediatric neurological disorder, affecting 4-10% of children in their first 16 years. There are several types of seizures including generalized and partial seizures. Febrile seizures are the most common type in childhood. Status epilepticus is defined as continuous seizure activity lasting longer than 30 minutes. The management of seizures involves stabilizing ABCs, stopping the seizure with benzodiazepines or other anticonvulsants, and performing diagnostic tests based on the history and physical exam findings. Febrile seizures are usually benign but the cause of fever needs to be identified.

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    Seizures are the most common pediatric neurological disorder, affecting 4-10% of children in their first 16 years. There are several types of seizures including generalized and partial seizures. Febrile seizures are the most common type in childhood. Status epilepticus is defined as continuous seizure activity lasting longer than 30 minutes. The management of seizures involves stabilizing ABCs, stopping the seizure with benzodiazepines or other anticonvulsants, and performing diagnostic tests based on the history and physical exam findings. Febrile seizures are usually benign but the cause of fever needs to be identified.

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    29 views6 pages

    18.d Seizures

    Uploaded by

    Samantha Lui
    Seizures are the most common pediatric neurological disorder, affecting 4-10% of children in their first 16 years. There are several types of seizures including generalized and partial seizures. Febrile seizures are the most common type in childhood. Status epilepticus is defined as continuous seizure activity lasting longer than 30 minutes. The management of seizures involves stabilizing ABCs, stopping the seizure with benzodiazepines or other anticonvulsants, and performing diagnostic tests based on the history and physical exam findings. Febrile seizures are usually benign but the cause of fever needs to be identified.

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    of 6

    CHAPTER 18.

    SEIZURES
    GEOFFREY HUNG MD, BSC, FRCPC, FAAP

    Seizures are the most common pediatric neurologist disorder. Four to ten percent of all
    children experience at least one seizure in the first 16 years of life.

    Objectives:
    1. know the key features of the history and physical exam in a child who presents
    with a seizure
    2. understand the 2 basic principles of managing a seizure
    3. know one first line and one second line anticonvulsant medication used in the
    management of status epilepticus
    4. describe the clinical features of a simple febrile seizure

    Definitions

    Seizure – a transient involuntary alteration of consciousness, behaviour, motor activity,


    sensation or autonomic function, caused by an excessive rate of discharges from a
    group of cerebral neurons. Most seizures will be followed by a postictal period
    proportional to the duration of the seizure.

    Epilepsy – condition of susceptibility to recurrent seizures

    Status epilepticus – continuous or recurrent seizure activity lasting longer than 30


    minutes without recovery of consciousness. Prolonged seizures may result in
    permanent neurologic sequelae.

    Classification of seizures
    Generalized – involve both cerebral hemispheres, may be tonic-clonic, tonic, clonic,
    myoclonic, atonic-akinetic, or absence. Generalized tonic-clonic are the most common
    type of seizure in children.

    Partial Seizures - may be simple (no altered LOC) or complex (with altered LOC). Both
    simple and complex can progress to a generalized seizure.

    Specific Seizure Syndromes can occur in children, like:


    Lennox-Gastaut
    Benign rolandic epilepsy
    Juvenile myclonic epilepsy of Janz
    Infantile spasms (West’s syndrome)

    (for a more detailed discussion of the classification of seizures and specific seizure
    syndromes in children see the review article in the references)

    1
    Differential Diagnosis

    When a child presents with what is called a “seizure”, first decide whether or not the
    child truly had a seizure.

    A detailed account of the event is the most important factor in making the correct
    diagnosis. Other diagnoses may mimic a seizure.

    Disorders that can mimic a seizure


    Apnea Syncope
    Breath-holding spells Arrhythmias
    Migraine Acute dystonia
    Benign myoclonus Pseudoseizures
    Shuddering attacks Tics
    Sleep disorders GE Reflux (Sandifer’s syndrome)

    Once you have established that a seizure has occurred, you must remember that a
    seizure is symptom of an underlying pathologic process.

    Causes of Seizures
    Infectious – encephalitis, meningitis, brain abscess, febrile seizure
    Neurologic – birth injury, congenital anomalies, degenerative disease, hypoxic-ischemic
    encephalopathy, neurocutaneous syndromes, VP shunt malfunction
    Metabolic – hypocalcemia, hyponatremia, hypoglycemia, hypomagnesemia, inborn error
    of metabolism
    Traumatic – accidental, non-accidental
    Toxicologic – alcohol, amphetamines, cocaine, TCA’s, isoniazid, salicylates
    – withdrawal of alcohol or anticonvulsants
    Idiopathic (Epilepsy)

    APPROACH
    1. Manage ABC’s
    2. Stop the seizure
    3. Detailed history and physical

    Management

    Most children present with having had a single afebrile generalized seizure, often there
    is no precipitating factor and they have a normal neurologic exam in the emergency
    department.

    After a thorough history and physical, these children need very little investigation in the
    ED and can be referred to a pediatrician or neurologist as an outpatient. One can also
    arrange for an outpatient EEG.

    2
    Any child arriving to the ED still having a seizure can be assumed to be seizing for at
    least 15 minutes or more and should be managed as status epilepticus.

    Management of status epilepticus

    The two basic principles are 1. managing the ABC’s and 2. stopping the seizure

    Airway – ensure airway is open, jaw thrust, may need oral or nasal airway
    Breathing – give oxygen
    Circulation – get iv access, check a glucose at the same time
    D – check the pupils, tone, posturing
    E – expose the patient, take a temperature

    STOP THE SEIZURE


    First line = benzodiazepines
    Lorazepam 0.1 mg/kg iv
    Diazepam 0.3 mg/kg iv or 0.5 mg/kg pr
    If seizure continues give second dose of benzodiazepine after 5-10 minutes

    Second line = long acting agents


    Phenytoin 18 mg/kg iv over 20 minutes in normal saline
    Phenobarbital 20 mg/kg iv

    If still seizing beyond 30 minutes - consider intubation

    Third line = Paraldehdye 0.3 ml/kg given rectally


    Midazolam infusion
    Pentobarbital infusion

    ICU consult
    Neurology consult

    *One the patient is stabilized, take a detailed history and physical.

    History
    Thorough description of events before, during and after the episode
    Duration of event
    Type of movements - rhythmic jerking, stiffness, loss of tone
    Eye deviation
    Pattern of breathing, cyanosis
    Unresponsiveness
    Presence of aura
    Incontinence
    Duration of post-ictal period
    Focal neurological signs after the seizure

    Any precipitating factors trauma


    toxic ingestion
    recent immunizations
    fever, systemic illness
    home remedies

    3
    If child has known seizure disorder is this a typical seizure
    how was it different
    any recent medication changes
    medication compliance

    Past medical history birth history


    neurologic disorder
    developmental delay
    VP shunt
    Recent travel
    Family history of seizures

    Physical examination
    First priority = ABC’s
    Is the airway patent?
    Is the child breathing? RR, O2 sat
    Assess circulation – HR, BP, iv access

    Get all the vital signs including temperature


    Head - dysmorphic features, signs of trauma, head circumference, bulging fontanelle
    Eyes – papilledema, retinal hemorrhages
    Neck – meningismus
    Skin – bruising, signs of neurocutaneous disorder eg. café au lait spots
    Neurologic exam – GCS, cranial nerves, tone, power, DTR’s, primitive reflexes in the
    infant

    Diagnostic Approach

    Always check blood glucose


    Drug level may be useful in the child taking an anticonvulsant

    Electrolytes, Calcium, Magnesium, Ammonia, CBC, toxicology screens should be


    performed based on clinical suspicion

    Routine lumbar puncture is not indicated in the child with a first afebrile seizure that has
    returned to baseline.

    Neuroimaging
    Indications for emergent CT scan – focal seizure, persistent seizure activity, focal
    neurologic deficit, VP shunt, neurocutaneous disorder, signs of raised ICP,
    history of trauma.
    Not necessary in the well appearing child with the first unprovoked afebrile
    seizure.
    EEG
    Most children can be referred for outpatient EEG
    Indications for emergent EEG include – refractory seizures or no convulsive
    status

    4
    FEBRILE SEIZURES

    Febrile seizures are the most common type of seizure in childhood, affecting 2-5% of the
    population.

    Definition
    Seizure occurring with fever but without evidence of intracranial infection or other
    defined cause

    Features of a simple febrile seizure


    Age – 6 months to 6 years
    Type of seizure – generalized tonic-clonic
    Duration – less than 15 minutes
    Recurrence – only 1 seizure in 24 hours
    Normal neurologic exam
    Normal developmental history
    Often a positive family history

    Features of complex febrile seizure


    Duration – greater than 15 minutes
    Recurrence – more than 1 in 24 hours
    Type – focal

    Risk of recurrence
    33% will have at least one recurrence
    75% of recurrences happen within one year

    Risk of epilepsy (afebrile seizures)


    1-2%
    factors that increase the risk of epilepsy
    - abnormal development prior to febrile seizure
    - complex first febrile seizure
    - positive family history of afebrile seizures

    Management

    Most children have simple febrile seizures and have stopped seizing on their arrival to
    the ED.

    After careful history and physical, one can often make the diagnosis of febrile seizures
    without any further investigation.

    However the cause of the fever must also be considered.


    Common causes of fever associated with febrile seizures include roseola, viral URTI,
    otitis media. If there is no apparent focus of infection, then treat the child like a patient
    with fever without source.

    A strong consideration for a lumbar puncture is made for all infants less than 12 months,
    and recommended for those with complex seizures or abnormal neurological exam.

    5
    Patients with simple febrile seizure can be safely discharged home. Parents need to be
    counselled on risk of recurrence and given simple instructions should another seizure
    recur.

    Anticonvulsants are not recommended.

    Antipyretics have never been shown to be effective in preventing future febrile seizures.

    REFERENCES

    1. Friedman MJ and Sharieff GQ, Seizures in children, Pediatric Clinics of North


    America, 53 (2), pages 257-277, 2006.
    2. Textbook of Pediatric Emergency Medicine, fourth edition, Editors Gary R.
    Fleisher and Stephen Ludwig, Chapter 70, 2000.

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