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GREAT LAKES UNIVERSITY OF KISUMU
FACULTY OF HEALTH SCIENCEDEPARTMENT OF CLINICAL MEDICINE
UNIT: PAEDIATRICS
TOPIC: CONVULSIVE DISORDERS
COURSE INSTRUCTOR : DR. KURIA M.STUDENT: KEVIN MMBIGURU
•Different types of seizures may occur in different parts of the brain and may be localized (affect only a part of the body) or widespread (affect the whole body).
•Seizures may occur for many reasons, especially in children. Seizures in newborns may be very different than seizures in toddlers, school-aged children, and adolescents
Characteristics of Seizure abrupt onset
brief duration (90-120 sec)
Altered mental status (except simple partial)
purposeless activity
unprovoked (except febrile)
postictal state (except simple partial and absence)
Although seizures have many known causes, for most children, the cause remains unknown.
In many of these cases, there is some family history of seizures.
The remaining causes include infections such as
Meningitis
developmental problems such as cerebral palsy
head trauma
Multiple sclerosis
Malaria
epilepsy
SEIZURES IN CHILDREN CAUSES
The most common type of seizure in children is the febrile seizure, which occurs when an infection associated with a high fever develops.Other reasons for seizures are these:
Metabolic disorders
Drugs
Medications
Poisons
Many yet undiscovered problems
febrile seizure A febrile seizure occurs when a child
contracts an illness such as an ear infection, cold, or chickenpox accompanied by fever. Febrile seizures are the most common type of seizure seen in children.
generalized seizure occurring during a sudden rise in temp in absence of intracranial infection or other defined etiology
Children who are developmentally delayed or who have spent more than 28 days in a neonatal intensive care unit are also more likely to have a febrile seizure.
One of 4 children who have a febrile seizure will have another, usually within a year.
Children who have had a febrile seizure in the past are also more likely to have a second episode.
Febrile Seizure: management ABCs and monitor VS
Check blood glucose
abort seizure if ongoing (benzodiazepine)
IV/IM/PR administration
Cooling measures
Neonatal seizures Neonatal seizures occur within 28 days of
birth. Most occur soon after the child is born. They may be due to a large variety of conditions.
It may be difficult to determine if a newborn is actually seizing, because they often do not have convulsions. Instead, their eyes appear to be looking in different directions.
They may have lip smacking or periods of no breathing.
Partial SeizuresSimple partial
Epileptic electrical discharge limited to focal area of cortex
Patients can interact normally with their environment except for limitations on localized brain function
Include subjective sensory and psychological phenomena
Auras affect about 60% of patients with focal epilepsy
Location of focus often predicts nature of pathology and directs testing
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With motor signs Begin with clonic (rhythmic jerking) or tonic (stiffening)
movements in body part
Large cortical representation
involves muscles of face and hand “Jacksonian march” – uncommon
homunculus representation: begins in primary motor cortex and spreads to involve rest of precentral gyrus
“Fencer’s posture” – common
ictal discharges involve secondary motor areas of frontal lobe
contralateral flexion and elevation of arm, contralateral turning of head and eyes, and tonic expression of ipsilateral arm
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Speech arrest, vocalizations, and eye blinking
Todd’s paralysis Transient neurologic abnormality – last <48
hours
Postictal depression of epileptogeniccortical area
motor seizure – focal weakness
sensory seizure – numbness
occipital lobe seizure – blindness
Focal abnormalities useful clues to site of origin
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Complex Partial Impair consciousness and produce
unresponsiveness
70% to 80% arise from temporal lobe
Remaining cases arise mainly from frontal lobe
Many evolve from simple partial as progresses
Uncinate fits
preceded by olfactory aura
arise in or near uncus of temporal lobe
13
Convulsive seizures are noted by uncontrollable muscle jerking lasting for a few minutes-usually less than 5-followed by a period of drowsiness that is called the postictal period.
The child should return to his or her normal self except for fatigue within around 15 minutes. Often the child may have incontinence (lose urine or stool), and it is normal for the child not to remember the seizure.
Sometimes the jerking can cause injury, which may range from a small bite on the tongue to a broken bone.
Convulsive seizures
Tonic seizures result in continuous muscle contraction and rigidity, while tonic-clonic seizures involve alternating tonic activity with rhythmic jerking of muscle groups.
Infantile spasms commonly occur in children younger than 18 months.
They are often associated with mental retardation and consist of sudden spasms of muscle groups, causing the child to assume a flexed stature. They are frequent upon awakening.
Tonic seizures
Generalized seizures involve a much larger portion of the brain.
They are grouped into 2 types:
convulsive (muscle jerking)
non convulsive
Generalized seizures
Generalized convulsions. The child may undergo rhythmic jerking and muscle spasms, sometimes with difficulty breathing and rolling eyes.
The child is often sleepy and confused after the seizure and does not remember the seizure afterward.
This symptom group is common with grand mal (generalized) and febrile seizures.
Children with absence seizures (petit mal) develop a loss of awareness with staring or blinking, which starts and stops quickly.
There are no convulsive movements. These children return to normal as soon as the seizure stops.
Repetitive movements such as chewing, lip smacking, or clapping, followed by confusion are common in children suffering from a type of seizure disorder known as complex partial seizures.
Complications
Oral trauma
Vertebral compression fractures
Shoulder dislocation
Aspiration pneumonia
Sudden death – acute pulmonary edema, cardiac arrhythmia, suffocation
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MOVEMENT SEIZURES
Movement seizures, which include partial seizures and generalized (grand mal) seizures, can be very dramatic..
If the child is on antiseizure medications, then the medication's levels in the blood are checked (if possible).
Children in status epilepticus are admitted to an intensive care unit.
If the child is doing well, doesn't have recurring seizures, and has a normal physical examination findings and blood test results, then the child will most likely be sent home to follow up with
Absence seizures, also known as petit mal seizures, are short episodes during which the child stares or eye blinks, with no apparent awareness of their surroundings.
These episodes usually do not last longer then a few seconds and start and stop abruptly; however, the child does not remember the event at all.
These are sometimes discovered after the child's teacher reports daydreaming, if the child loses his or her place while reading or misses instructions for assignments
ABSENCE SEIZURES
Atypical absenceMore gradual lapses of awareness
Not resolve as abruptly
Autonomic features or loss of muscle tone
Most often in mentally retarded children
Not respond as well to drugs
MyoclonicRapid, recurrent, brief muscle jerks
Can occur bilaterally, synchronously or asynchronously, or unilaterally without LOC
Often cluster shortly after waking or while falling asleep
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Status epilepticus is either a seizure lasting longer than 30 minutes or repeated seizures without a return to normal in between them.
It is most common in children younger than 2 years, and most of these children have generalized tonic-clonic seizures.
Epilepsy refers to a pattern of chronic seizures of any type over a long period. Thirty percent of children diagnosed with epilepsy continue to have repeated seizures into adulthood, while others improve over time
STATUS EPILEPTICUS
Status Epilepticus: Considerations
Generalized convulsive activity results in: hypoxia
hyperpyrexia
BP instability and cerebral dysautoregulation
respiratory and metabolic acidosis
hyperazotemia/hypokalemia/hyponatremia
hyperglycemia followed by hypoglycemia
marked elevations of prolactin, glucagon, growth hormone and corticotropin
rhabdomyolysis may produce myoglobinuria and renal failure
Status Epilepticus: Management Rapid Seizure control
Step 1: ABC’s
NPA, OPA If rapid sequence intubation (RSI) needed use only short acting
paralytics
blood glucose Cardiac Monitor IV access HPI/PE
Further specific treatment based upon circumstance
Status Epilepticus: Management Step 2: 1st line drugs
Step 3: 2nd line drugs
Step 4: 3rd line drugs
The longer the seizure continues; The more difficult it is to stop
The more likely permanent CNS injury will occur
Medication Options First line
diazepam (Valium) IV/PR lorazepam (Ativan)IV/IN midazolam (Versed)IV/IM
Second line phenytoin/fosphenytoin phenobarbital
Lastly induction of anesthesia w. cont. EEG Infusions of midazolam, diprivan, valproic acid,
pentobarbital Inhaled isoflurane
CEREBRAL PALSY Disorder of movement acquired prenatally, perinatally
or in early childhood.
Secondary to brain insult (motor area or motor tracts).
Lesion non progressive.
Clinical picture non static (variable over time).
Aetiology:
Prenatal
Perinatal
Postnatal causes.
Aetiology:
Prenatal
Inherited disorders.
Intrauterine infections.
Cerebral malformation.
Toxic substances.
Aetiology:
Perinatal
asphyxia.
Prematurity.
Intracranial Trauma/ haemorrhage.
Neonatal seizures.
Kernicterus.
Infections.
Aetiology:
Postnatal
Infections like meningitis, encephalitis.
Encephalopathy.
Intracranial Trauma/ haemorrhage.
Metabolic disorders e.g dehydration.
Aetiology:
Incidence is variable, about 2:1000 children.
Higher rates in the under-developed societies.
In developing societies perinatal causes common.
Inherited causes in developed countries.
Classification/ Types:
Anatomical.
Physiological.
Functional
Classification/ Types:
Anatomical: based on limb involvement.
Hemiplegic
Diplegic
Quadriplegic
Paraplegic
Classification/ Types:
Physiological:based on tone of the muscles & associated activities.
Spastic cerebral palsy
Features include: increased muscle tone, brisk reflexes, upgoing plantar reflexes.
Hypotonic type.
Reduced muscle tone at rest but increased on activity.
Physiological.
Extra pyramidal: athetoid, choreo-athetoid movements.
Writhing movements predominate (with chorea
Associated with basal ganglia lesion.
Hyperbilirubinaemia and prematurity are known causes.
Deafness is common.
Classification/ Types:
Physiological.
Ataxic:
cerebellar dysfunction predominant.
Lack of balance and broad based gait.
Inco-ordination, hypotonia and nystagmus may occur.
Mixed type of any of the above features.
Diagnosis
Features in diagnosis include:
Cerebral insult.
Irritability.
Violent startle reaction.
Seizures.
Apathy, poor feeding.
Diagnosis - features
Floppy infant.
Stiffness.
Delayed motor milestones.
Stereotyped movements.
Micro- / macro-cephaly.
Strong hand preference in the first year.
Parental anxiety.
Associated Problems:
Seizures (occur in 25-35% of CP).
Mental retardation.
Specific learning disabilities.
Sleep disorders.
Hyperactivity.
Associated Problems:
Flexor spasms/ contractures.
Language deficit/ deafness.
Feeding difficulties/ constipation/ incontinence.
Infections esp resp. tract infection.
Misery/ distress to the family/ psychological problems.
Management
Counselling and health education to parents.
Treat the associated seizures.
Physiotherapy/ occupational therapy.
Surgery – Rhizotomies, tendon/ contractures release.
Management
Speech therapy.
Intellectual assessment for school placement.
Prognosis
Variable dependent on:
Rehabilitative resources.
Timing of rehabilitation.
Infrastructure.
Associated disorders / complications
Severity of lesion.
Recommended