Approach in Children With Seizures

8/10/2019 Approach in Children With Seizures

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Seizure: transient occurrence of signs/symptomsresulting from abnormal excessive or synchronousneuronal activity in the brain

Seizure: focal (partial) and generalized Epilepsy: brain disorder in which an individual

endures predisposition to generate seizures. i.e. : 1 unprovoked epileptic seizure + (second similar

seizure OR EEG and clinical info convincingly demonstratethe predisposition)

Epidemiologic purpose: 2 unprovoked seizure within >24 hr


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4-10% children has at least 1 seizure before16 y0.

Lifetime incidence of epilepsy: 3% 30% of those who have 1stfebrile seizure

epilepsy


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SeizureMedical Emergency!

Airway, Breathing, Circulation

Vital signs (temperature, blood pressure, heartrate, respiratory rate)

Blood glucose

Serum electrolytes

Potentially life-threatening: meningitis,sepsis, head trauma, drug abuse,intoxication.


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1. Focal or generalized?2. Duration of seizure

3. State of

consciousness

4. Presence of aura5. Posture

6. Cyanosis7. Loss of sphinctercontrol

8. Postictal state

Physical Exam:

Head circumference,anthropometric studies.

General examination

Neurologic examination


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Seizures that occur between age of 6-60 mowith a temperature > 38oC in the absence ofCNS infection, metabolic imbalance orhistory of afebrile seizures.

Type: simple and complex. Risk factors of subsequent epilepsy:

neurodevelopmental abnormalities (33%),focal complex febrile seizure (29%), familialhistory of epilepsy (18%), fever < 1 hr (11%),recurrent febrile seizure (4%)


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Lumbar puncture?

1stFS in children < 12 mo

Children with seizurebetween 12-18 mo

> 18 mowith clinicalsuspicion only

EEG?

After 2 wks passed theseizure


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Blood studies

Based on indicationsonly!

CBC, serum electrolytes,RBG, Ca, Mg, P

Neuroimaging

Not indicated in firstfebrile seizure


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Counselling on RR of recurrence of FS andepilepsy and how to handle the seizure

Acute treatment of seizure with diazepam,lorazepam, or midazolam accordingly Intermittent oral diazepam: 0.33 mg/kg q8h,

during fever Antipyretic agents to reduce fever What about other AEDs? Any indications?


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DRUG ROUTE DOSAGE (mg/kg)

LorazepamIntravenous 0.05-0.1

Intranasal 0.1

Midazolam

Intravenous0.2 loading0.08-0.23/hrmaintenance

Intramuscular 0.1-0.5

Intranasal 0.2-0.3

Buccal 0.2-0.5

Diazepam

Intravenous 0.2-0.5

Rectal

2-5 yr: 0.5

6-11 yr: 0.3

12yr: 0.2

Phosphenytoin Intravenous15-20 PE, then 3-6/24 hr

Paraldehyde

Intramuscular 0.2 mL/kg

Rectal 0.4 mL/kg + samevolume of olive oil

Phenobarbital 5-20

Pentobarbital coma 13.0, then 1-5/hr

Propofol1 (bolus), then 1-15/hr (infusion)

Thiopental5/1st hour, then 1-2/hr

Valproate IntravenousLoading: 25, then

30-60/24 hr


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AGEGENERALIZED

PAROXYSMS

ABNORMAL

MOVEMENTS

AND POSTURES

OCULOMOTOR

ABNORMALITIES

SLEEP

DISORDERS

Neonate

Apnea

Hyperekplexia

Jitteriness

Paroxysmal

extreme pain

disorder

Jitteriness

Paroxysmal

dystonic

choreoathetosis

Paroxysmal tonic

up gaze

Alternatinghemiplegia of

childhood

Benign neonatal

sleep myoclonus

Sleep transition

disorders


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AGEGENERALIZED

PAROXYSMS

ABNORMAL

MOVEMENTS

AND POSTURES

OCULOMOTOR

ABNORMALITIES

SLEEP

DISORDERS

Infants Hyperekplexia

Reflex anoxic

seizures

Breath-holding

spells

Benign paroxysmal

vertigoPathologic startle

Paroxysmal

extreme pain

disorder

Jitteriness

Sandifer

Paroxysmal

dystonic

choreoathetosis

Benign myoclonus

of early infancyShuddering

attacks

Benign

paroxysmal

torticollis

Psychological

disorders

Alternating

hemiplegia of

childhood

Jactatio capitis

head banging

Drug reactions

Paroxysmal tonic

upgaze

Oculomotor

apraxia

Spasmus nutans

Opsoclonus

myoclonussyndrome

Non-REM partial

arousal disorders

REM sleep

disorders

Narcolepsy

Sleep transition

disorders(somnambulism,

somniloquy)


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AGEGENERALIZED

PAROXYSMS

ABNORMAL

MOVEMENTS

AND POSTURES

OCULOMOTOR

ABNORMALITIES

SLEEP

DISORDERS

Children and

adolescents

Benign

paroxysmalvertigo

Pathologic startle

Compulsive

valsalva

Alternating

hemiplegia of

childhoodFamilial hemiplegic

migraine

Syncope (Long QT,

vasovagal,

vagovagal,

orthostatic,

migraine-induced)

Psychogenic

seizures

Cataplexy

Transient global

amnesia

Hyperventilationspells

Tics

TremorParoxysmal

dyskinesias

Benign paroxysmal

torticollis

Episodic ataxia

Psychologic

disorders includingMunchausen

syndrome by

proxy, malingering

Masturbation

Jactatio capitis

(head banging)

Episodic rage

Drug reactions

Daydreaming

Drug reactions

Non-REM partial

arousal disordersREM sleep

disorders

Narcolepsy

Sleep transition

disorders

(somnambulism,

somniloquy)Sleep myoclonus

Restless legs

syndrome


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1. A 4-yr-old boy is evaluated for his first generalized tonic-clonic seizure,which lasted 10 min. There is no history of illness or fever, and findingson examination an hour after the seizure are completely normal. Themost appropriate management is:

Begin therapy with CBZ Order an EEG

Order a CT Scan of the brain

Order an MRI Study of the brain

Order psychometric testing


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2. A 15-mo-old girl is evaluated for a 10-min-long generalized seizureassociated with a temperature of 40oC. Which of the following factorsin the history is most likely to increase the risk of future seizures?

APGAR Score of 3 at 5 minutes

Family history of epilepsy Clinical evidence of roseola

Female gender

Presence of 2 caf-au-lait spots


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3. A 3-yr-old boy is being evaluated after an episode at home duringwhich he lost consciousness for 5 min; he was brought to theemergency department an hour later. On examination, which of thefollowing factors is most helpful in distinguishing whether this episode

was a seizure or syncope? Family history

Temperature

Blood pressure

Level of consciousness

Size of pupils


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4. Please draw the algorithm of acute treatment in children with seizures.


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5. Please explain how to prepare the administration of phenobarbital as ifyou were discussing the drug with the nurses.


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Homework:

Epilepsy

Types of AEDs and their

indications

CNS infections and theirtreatments

Congenital anomalies of

CNS with seizurepresentation and theirtreatments

Documents

Approach in Children With Seizures