Convulsive disordes

CONVULSIVE DISORDES

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Najah QasemQassim University

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Objectives:

1- define the etiological factors of seizures in children.2- discuss febrile convulsion in children and its

treatment.3- list classification of epileptic seizures.4- explain characteristics for epileptic seizures’ types.5- identify diagnostic procedures .6- numerate treatment principles for epilepsy7- identify seizures precautions.8- formulate nursing care plan for a child with epilepsy.9- discuss status epilepticus and initial approach

treatment.10- plan drug study for some medications.

OVER VIEW

Convulsive phenomena are among the most frequently observed neurological dysfunctions in children and can occur with a wide variety of conditions involving the C.N.S

3-5% of all children will have one or more seizures .

The incidence of epilepsy (new cases per year) has been reported to be 50/100,000

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Etiology of Seizures in Children

classification of seizures is presented in the following : A) Acute/Non-recurrent

(i) with fever: febrile convulsion, infections e.g. meningitis, encephalitis. . (ii) without fever: poisoning including medicinal overdose, metabolic disturbance e.g. hypoglycemia, hypocalcaemia and electrolyte imbalance, head injury, brain tumor. 4

Etiology of Seizures in Children

B) Chronic/Recurrent : (i) with fever: recurrent febrile convulsion. (ii) without fever: epilepsy.

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Febrile seizures

Febrile convulsions, the most common seizure disorder during childhood.

Occurring between 6 months and 6 years.

Precipitated by fever from: infection/inflammation/metabolic disorders .

It is not a form of epilepsy because brain is normal.

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Febrile seizures

In most cases it is generalized tonic - clonic convulsion. and lasts a few seconds to less than 15 minutes with a loss of consciousness.

There is no preceding aura and the childmay be postictal (confused) for a short

time after the seizure is over. A strong family history of febrile

convulsions.7

Clinical Picture Febrile convulsion is divided into three main groups based on symptoms of the

seizure:Simple febrile convulsion (convulsion

occur in majority of the cases ~ 75%, lasting less than 15 minutes , not having focal features, single in 24 hours).

Complex febrile convulsion: represent 25% of the cases, lasting more than 15 min, with focal features, multiple in 24 hours.

Febrile status epilepticus.8

Treatment of Febrile Seizures

A careful search for the cause of the fever. Use of antipyretics. Reassurance of the parents. Prolonged anticonvulsant prophylaxis for

preventing recurrent febrile convulsions is controversial and no longer recommended.

Oral diazepam, 0.3 mg/kg/8h or (1mg/kg/24hr), is administered for the duration of the illness (usually 2–3 days).

Vaccination is not contraindicated. No treatment is effective in decreasing risk of

future epilepsy. 9

Counseling of the Parents

Parents should be informed about the benign nature of febrile convulsion and that it

may recure. Parents should be taught to manage the

convulsion by placing the child in recovery position (lying in his or her side to prevent aspiration and control fever).

After the seizure subsides, parents should sponge the child with tepid water to reduce the fever quickly.(applying alcohol or cold water is not advisable, because extreme cooling cause shock to an immature nervous system)

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Epilepsy

Epilepsy is a group of syndromes characterized by recurring seizures.

seizure is an involuntary contraction of muscle caused by abnormal electrical brain discharges.

Epilepsy can be primary (idiopathic)or secondary, when the cause is known and

the epilepsy is a symptom of another underlying condition such as a brain tumor

Classification of Epileptic Seizures (recurrent

seizures) Partial (Focal) seizures:

Simple partial seizures (no altered level of consciousness)

Simple partial seizures with motor signs (include aversive, rolandic, and jacksonian march).

Simple partial seizures with sensory signs.

Complex partial (psychomotor) seizures (some impairment or alteration in level of consciousness)

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Classification of Epileptic Seizures (recurrent

seizures) Generalized seizures

Generalized tonic – clonic seizure (Grand Mal) Absence seizures (Petit Mal). Atonic seizures (Drop Attacks) Myoclonic seizures. Akinetic seizures Infantile spasms

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Partial (Focal) Seizures

Simple partial seizures with motor signs:

It arises from the area of the brain that controls muscle movement. A common motor seizure in children is:

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i) Aversive seizure: the eye or eyes and head turn away from the

side of the focus. In some children the upper extremity toward

which the head turns is abducted and extended.

The fingers are clenched giving the impression that the child is looking at the closed fist.

The child may be aware of the movement.15


ii) Rolandic seizure: Tonic- clonic movements involving the

face. Salivation. Arrested speech. Most common during sleep. It is the common form.

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iii) Jacksonian March: Consists of orderly, sequential

progression of clonic movements that begin in a foot, hand, or face, and as electric impulses spread from the irritable focus to contiguous regions of the cortex, move or march body parts activated by these cerebral regions.

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2. Simple partial seizures with sensory signs:

Characterized by various sensations including numbness, tingling, prickling, or pain that originates in one area e.g. face or extremities and spreads to other parts of the body.

Visual sensations or formed images, hallucinations, tight flashes, tastes, smells, or sounds may be experienced.

Autotonic activity may include pallor, sweating, flushing, and pupil dilation.

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Partial (Focal) Seizures3. Complex Partial Seizures (Psychomotor Seizures)Vary greatly in extent and symptoms and tend to

be the most difficult type to control. Are observed more often in children from 3 years

of age through adolescence. May begin with a slight aura in the form of

sensation of strange feeling at the bottom of the stomach that rises toward the throat.

This feeling may be accompanied by unpleasant odors or taste, complex auditory or visual hallucinations.

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Cont.. Impaired consciousness ; the child may

appear dazed and confused and be unable to respond when spoken to or to follow instruction.

Automatisms (repeated activities without purpose and carried out in a dreamy state), such as oropharyngeal activities as chewing, drooling, or swallowing.

Ambulatory activities as wandering or running and verbal manifestations such as repeating word.

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Generalized Seizures I- Tonic - Clonic Seizures:

(Grand Mal) It is consisting of four stages:A- prodromal period of hours or days.B- an aura, or warning, immediately before

the seizure.C- the tonic-clonic stageD- postictal stage.* Not all four stages occur with every seizure.

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cont..

A- prodromal period of hours or days.May consist of drowsiness, dizziness, malaise,

lack of coordination, or tension. B- an aura, or warning, immediately before

the seizure.May reflect the portion of the brain in which

the seizure originates. Smelling unpleasant odors denotes activity in the medial portion of the temporal lobe. Seeing flashing lights suggests the occipital area. Repeated hallucination arise from the temporal lobe.

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cont..

C- the tonic-clonic stageTonic phase: rolling of the eyes upward immediate loss of consciousness stiffness in the entire body muscles, and the child

falls to the ground. arms usually flex, whereas the legs, head and

neck extend. lasts approximately 10 to 20 seconds the child is an apnea and may become cyanotic Autonomic stimulation causes increased salivation.

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cont..

Clonic phase: intense jerking movements as the trunk

and the extremities undergo rhythmic contraction and relaxation.

child may foam at the mouth and incontinent of urine and feces.

It lasts about 20 to 30 seconds up to 30 miutes.

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cont..D- postictal stage Falls into a soundly sleep for 1 to 4 hours

and will rouse only to painful stimuli during this time.

Child may have visual and speech difficulties and may vomit or complain of severe headache.

The child has no memory of the seizure.

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2- Absence Seizures: (Petit Mal)

Occur more frequently in girls than boys Onset of absence seizures is abrupt and the

child suddenly develops up to 100 attacks daily. Brief loss of consciousness with minimal or no

alteration, usually consist of a staring spell that lasts for a few seconds.

Rhythmic blinking and twitching of the mouth or an extremity may accompany the staring.

The sudden -rest of activity and consciousness is not accompanied by incontinence, and the child has amnesia for the episode.

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cont..

Slight loss of muscle tone may cause the child to drop objects, but he can maintain postural control.

usually lasts approximately 5 to10 seconds. usually have normal intelligence, however, if

they have frequent episodes, they may be doing poorly in school because they are missing instructional content.

Petit mal seizures can be precipitated by hyperventilation, fatigue, hypoglycemia, stresses (emotional and physiological) or sleeplessness.

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3- Atonic Seizures: (Drop Attacks)

Manifested as a sudden, momentary loss of muscle tone. Onset is usually between 2 and 5 years of age. During a mild seizure the child may simply

experience several sudden brief head drops. During a more severe episode, the child will

suddenly fall to the ground and will lose consciousness briefly and after a few seconds will get up as if nothing happened.

Frequent falls can result in injury to face, particularly the chin, eyebrow and nose area.28

4- Myoclonic seizures: Include sudden, brief contractions of a muscle or group of muscles. No loss of consciousness or postical state. Myoclonus often appears normally in the course

of falling asleep. May be confused with the exaggerated startle

reflex, but may be distinguished by placing one's palm against the back of the child's head, if it is possible to push the child's head forward, this indicates an exaggerated startle reflex. In case of a myoclonic seizure, the child's head resists attempts to bring head forward.29

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5- Akinetic seizures:

Are characterized by lack of movement, however muscle

tone is maintained so the child freezes into position and doesn't fall. If the child is lying down, the evaluation of muscle tone helps to differentiate between the atonic and Akinetic type seizure. There is impairment or loss of consciousness

6- infantile spasm:(unclassified seizures)

characterized by Very rapid movements of the trunk with sudden

strong contractions of most of the body, including flexion and adduction of the limbs.

The infant suddenly slumps forward from a sitting position or falls from a standing position.

These episodes may occur singly or in clusters as frequently as 100 times a day.

Most common during the first 6 months of life Apparently result from a failure of normal

organized electrical activity in the brain.

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6- Infantile Spasm:(unclassified seizures)

the seizures may accompany a preexisting form of neurologic damage. In approximately 50% of those affected, there is an identifiable cause such as trauma or a metabolic disease. In the other 50%, there may be no identifiable cause.

Approximately 90% of these infants are developmentally delayed

In infants whose development was previously normal, intellectual development appears to halt and even regress after seizures start.

The infantile seizure phenomenon seems to “burn itself out” by 2 years of age but the associated cognitive or developmental delay remains.

Diagnostic Evaluation:

Has two major aims:1. To identify the type of seizures the child

has experienced, their frequency and severity, and the factors that precipitate them

2. To attempt to understand the cause of it. It includes:i. Perform complete history, physical

examination and neurologic examination, ii. Rule out metabolic causes with

measurements of serum glucose and electrolytes.

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Diagnostic Evaluation:

iii. Electroencephalography (EEG) records electrical activity of brain.

iv. Radiographic examination identifies cranial abnormalities.

v. Single photon emission computed tomography (SPECT).

It is useful for identifying the epileptogenic zone so that the area in the brain giving rise to seizures can be removed surgically

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Abnormalities in the EEG usually continue between seizures or, if not apparent, may be elicited by hyperventilation or during sleep.

Treatment of Epilepsy principles

Drug treatment should be regular Simple as possible Minimum of side effects Monotherapy Changes should be made gradually High initial dosages increases side

effects Rapid withdrawal carries the risk of

provoking status Always calculate the dosage according

to the weight 36

SEIZURE PRECAUTIONS

Extent of precautions depends on type, severity, and frequency of seizures

May include: Siderails raised when child is sleeping or

resting Siderails and other hard objects padded Waterproof mattress/pad on bed/crib Appropriate precautions during potentially

hazardous.

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SEIZURE PRECAUTIONS

Swimming with a companion Use of protective helmet and padding

during bicycle riding. Supervision during use of hazardous

machinery/equipment Have child carry or Wear medical

identification Alert other caregivers to need for any

special precautions38

Nursing Care Plan for the Child with Epilepsy1- Nursing Diagnoses: High risk for injury related to sudden seizure,

tonic-clonic seizureGoal:Child exhibits no signs of aspiration or traumatic

injury. Nursing interventions:1- If child is standing or sitting in wheelchair at

beginning of attack, ease child down so that he will not fall, when possible place a blanket under child. 39

Nursing interventions:2- Remain with child, and be calm.3- Loosen restrictive clothing.4- Prevent child from hitting head on sharp

objects that might cause injury.5- Remove hazards (Furniture).6- Pad objects such as crib.7- Keep side rails raised to avoid falls.8- Gently support child. Do not force hard

object between the teeth when Jaw is tightly closed.

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Expected outcome:Child exhibit no evidences of physical injury. Goal 2:Prevent seizures. Nursing interventions:1- Avoid situations that are known to

precipitate a seizure as blinking light, emotional stress, loud voice.

Expected outcome:Child remains free of seizure activity.

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2- Nursing diagnosis: self concept disturbance in body image, self esteem, personal identity related to seizure onsetGoal:Develop a positive self concept. Nursing interventions:1- Encourage child to express feelings and

concept about the disease.2- Encourage child to discuss his thoughts about

his disorder.3- Help child asses his strengths.4- Emphasize strengths.5- Help child set realistic goals. 42

3- Nursing Diagnosis:Altered family process related to emergencies hospitalization of child, knowledge deficit. Nursing Diagnosis: Interrupted family processes

related to diagnosis of long-term illness in childGoal 1: Support parents. Nursing intervention:1- Allow expression of feelings regarding the child's disorder, its implications.2- Refer to organizations to seek advice. 3- Be available to families for help.

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Expected outcome: Family expresses feelings and concerns. Family contacts agencies for help.Goal 2:Understand the disease Nursing intervention:1- Assist family in understanding the disorder,

its therapies, and possible complications.2- Help family to achieve realistic view about

the child and his capabilities.Expected outcome:Family demonstrates an understanding the

disorder, its therapy and implications.44

Goal 3:Prevent complications from medicationNursing intervention:1- Be aware of and teach family recognizes

unfavorable reactions to medications.2- Encourage periodic physical and laboratory

assessment to determine deviations from normal findings.

Expected outcome:Child and family demonstrate understanding of

possible unfavorable responses to medication and the appropriate intervention,

Goal 4:Prepare family for home care. 45

Nursing intervention:1- Teach administration of medications.2- Teach seizure prevention and management.3- Educate parents and child about appropriate

activities for the child:- Avoid contact sports.- Avoid situations that pause a danger during a

seizure like climbing trees.- Provide companionship during permissible

activities such as swimming, bicycling. Expected outcome:1- Family complies with instructions.2- Family demonstrates proper management of the

child during a seizure. 3- Child exhibits no evidence of physical injury.

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Status Epilepticus Refers to a seizure that lasts continuously for

longer than 30 minutes or a series of seizures from which the child doesn’t return to his or her level of consciousness.

Three major subtypes: prolonged febrile seizures idiopathic status epilepticus symptomatic status epilepticus

Severe anoxic encephalopathy in first few days of life.

The relationship between the neurologic outcome and the duration of status epilepticus is unknown in children.

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Complications

It is emergency situation that need immediate treatment

Hypoxemia Acidemia Glucose alterations Blood pressure disturbances Increased intracranial pressure High Morbidity

Neurologic sequelae Focal motor deficits Mental retardation Behavioral disorders Chronic epilepsy Acute and chronic MRI changes

High mortality (3-4%)

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Prolonged seizures

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Duration of seizure

Life threatening

systemicchanges

DeathTemporary

systemicchanges

Management of Status Epilepticusin Children--Initial Approach

Initial assessment A, B, Cs Rapid neurologic examination Brief history Give high flow oxygen

Measure rapid blood glucose More to avoid glucose infusion than the uncommon

hypoglycemic seizures Confirm epileptic seizure

Not all events are epileptic!!!! Laboratory Studies

Glucose, electrolytes, calcium, magnesium ABG CBC Serum anticonvulsant drug levels (if indicated) Toxicology screening

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Treatment of status epilepticus

Drugs: should always be administered IV phenytoin forms a precipitate in glucose solutions have resuscitation equipment at the bedside diazepam may be used initially if the seizures persist, phenytoin is given

immediately The choices for further drug management include

paraldehyde, a diazepam infusion, barbiturate coma, or general anesthesia.

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Drug study examples Drug study for PhenobarbitalClassification: CNS depressant.Action: acts as an anticonvulsant by lowering the

seizure threshold.Dosage: 3 to 6 mg/kg/day parenterally, for 7 to 10

days until a blood level of 10 to 15 µg/ml is achieved, or 10 to 15 mg/kg/day IV or IM.

In status epilepticus , 15 – 20 mg/kg IV administered over 10 to 15 minutes.

Possible adverse effects: sedation, confusion, lethargy, excitement, nausea, vomiting, constipation, diarrhea, epigastric pain, bradycardia, hypotention, syncope, hypoventilation, respiratory depression, pain or tissue necrosis at the injection site.

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Nursing implication1- when giving phenobarbital parenterally, administer IV

dose slowly, direct into tubing or running infusion. Inject a partial dose and assess the response before continuing. If giving phenobarbital IM administer it deeply into a large muscle.

2- monitor the IV site carefully for signs of irritation or extravasation.

3- assess vital signs closely during IV administration.4- administer oral form of the drug with food to minimize

gastrointestinal upset, instruct the parents to do the same.

5- caution the parents and child that the drug will make the child drowsy. Advise the child to change positions slowly and to sit at the edge of the bed for a few minutes before arising. Assist parents with safely measures to protect the child from injury.

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Nursing implication6- monitor laboratory tests for liver and renal function and

blood counts if the child is on long-term therapy.7- inform parents about the possible need for follow-up

laboratory tests.8- suggest that the parents obtain a medical alert bracelet

and have the child wear it in case of emergency.9- instruct parents and child to avoid over-the-counter

drugs, which could cause increased CNS depression.10- warn parents not to discontinue the drug abruptly or

change the dose unless ordered by the health care provider.

11- instruct parents to notify the health care provider if the child develops severe dizziness, weakness, or drowsiness that persists.

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Drug study examples Drug study for Phenytoin (Dilantin)Classification: it is an anticonvulsant.Action: Stabilizes neuronal membranes, prevents

hyperexcitability caused by excessive stimulation, and limits the spread of seizure activity without causing general central nervous system depression

Dosage: Initially, 5 mg/kg/day in two to three equally divided doses up to a maximum of 300 mg/day with a maintenance dose of 4 to 8 mg/kg/day.

Possible Adverse Effects: Nystagmus, ataxia, slurred speech, confusion, fatigue, irritability, nausea, gingival hyperplasia, liver damage, and blood dyscrasias

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Nursing Implications

1- Administer the drug with food to minimize gastrointestinal upset and enhance absorption. Instruct parents to do the same.

2- Advise parents to have the prescription filled each time with the same brand of drug, because differences in bioavailability have been reported.

3- Obtain serum drug levels as ordered to monitor for effectiveness and to prevent possible toxicity. Keep in mind that the therapeutic range is 10 to 20 µg/mL.

4- Monitor liver function studies and blood counts periodically.

5- Inform parents about the need for follow-up laboratory tests.

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Nursing Implications

6- Instruct the child and parents about oral hygiene measures to prevent gum problems. Encourage frequent dental checkups.

7- Suggest that the parents obtain a medical alert bracelet and have the child wear it in case of an emergency.

8- Caution parents not to discontinue the drug abruptly or change the dose unless ordered by the health care provider.

9- Instruct parents to notify the health care provider if the child develops nystagmus, ataxia, or diminished mental capacity. These are signs of possible toxicity.

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Convulsive disordes