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Pediatric Seizures

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Title: Pediatric Seizures


1
Pediatric Seizures
  • Muhammad Waseem, MD
  • Emergency Medicine
  • Lincoln Hospital

2
Few things are more frightening to parents than
to witness their child having a seizure
3
Objectives
  • Wide spectrum of Pediatric seizure
  • Etiologies specific to children
  • Treatment modalities in children
  • Quality of life issues
  • Legal implications

4
Seizure
  • Common neurologic disorder
  • 3 - 5 of children
  • 1/2 classified as febrile seizures
  • Epilepsy (0.5 - 1)

5
Seizure
  • 10 ambulance calls for children
  • 1.5 of total ED visit
  • Most resolve in the pre-hospital setting

6
Seizure - ED visits
  • Febrile seizure 53
  • Established epilepsy 31
  • New-onset seizure 10
  • Status epilepticus 5

7
Causes
  • Idiopathic 76
  • Developmental 13
  • Infection 5
  • Head trauma 3
  • Other 2

8
Seizure
  • Fit
  • Spell
  • Attack
  • Convulsion

9
What is Seizure?
10
Seizure
  • Paroxysmal, time-limited event that results from
    abnormal neuronal activity in the brain
  • Paroxysmal alteration in neurologic function
    (i.e, behavioral, motor, or autonomic function,
    or all three - volpe 1989.

11
Convulsion
  • A seizure with prominent motor manifestation

12
Epilepsy
  • Disorder of CNS whose symptoms are seizures
  • Recurrent seizures
  • Unprovoked

13
Seizure
  • Most seizures are not epileptic
  • Non-epileptic seizures are physiologic
  • Hypoxia
  • Fever
  • Toxins

14
Seizure
  • Seizure is a symptom of a disorder that need
    further investigations
  • Does not constitute a diagnosis
  • May occur in both normal abnormal tissue

15
Non-epileptic Events
16
Mimic Seizures
  • Breath-holding spells
  • Syncope
  • Migraine
  • Tics
  • Night terror
  • Pseudo-seizures

17
Non-epileptic Events
  • Inaccurate diagnoses
  • Inappropriate use of AED

18
Non-epileptic Events
  • Careful history

19
Breath-holding spells
  • Frightening
  • 6 months - 4 years
  • Inciting event-Shrill cry-Breath holding-Cyanosis
  • Disappear spontaneously before school age

20
Night Terrors
  • 5 - 7 years
  • Between midnight and 2 AM
  • Slow wave sleep stage 3 or 4
  • Frightened and screaming
  • Increased autonomic activity
  • Sleep follows in few minutes
  • No recall

21
Pseudo-seizure
  • Diagnosis of exclusion
  • 10 - 18 years
  • Bizarre, unusual postures
  • Verbalization
  • Uncharacteristic movements
  • Can be persuaded to have an attack on request

22
Pseudo-seizure
  • Lack of cyanosis
  • Talking during seizure
  • Normal reaction to pupil
  • No loss of sphincter control
  • Normal plantar responses
  • Lack of post-ictal drowsiness
  • Poor response to AED

23
Seizure
  • First step in identifying the epileptic syndrome
    is correctly identifying the type of seizure

24
Why Should I know type of Seizure?
25
Seizure
  • Clue to cause
  • Appropriate treatment
  • Prognosis

26
Epileptic Seizures
  • Partial (40)
  • Generalized
  • Unclassified

27
Partial Seizure
  • Simple Partial
  • Complex Partial
  • Partial with secondary generalization

28
Generalized
  • Convulsive
  • Non convulsive
  • Absence Seizure

29
Generalized- Convulsive
  • Myoclonic
  • Clonic
  • Tonic
  • Tonic-clonic
  • Atonic

30
Simple Partial Seizures (SPS)
  • Consciousness not altered
  • Aura
  • Motor activity (face, neck or extremity)
  • Feeling funny or something crawling inside
    me
  • No post-ictal phenomenon

31
Complex Partial Seizures (CPS)
  • Impairment of consciousness
  • Aura
  • Brief blank stare or sudden cessation or pause in
    activity
  • Automatism (lip smacking, chewing, swallowing and
    excessive salivation)

32
Complex Partial Seizures (CPS)
  • Dystonic posturing, tonic or clonic movement
  • Postictal phase
  • Duration 1 - 2 minutes
  • Usually during waking hours

33
Absence Seizure
  • Sudden cessation of motor activity or speech
  • Blank facial expression
  • Flickering of eye lids

34
Absence Seizure
  • Uncommon before age 5 year
  • Girls
  • No Aura
  • No postictal state
  • Rarely persist longer than 30 sec

35
Absence Seizure
  • Hyperventilation induces an absence seizure
  • 3/sec spike on EEG

36
Myoclonic
  • Quick muscle jerks
  • Loss of body tone
  • Consciousness usually unimpaired
  • Specific epilepsy syndromes

37
Tonic
  • Tonic spasms of truncal facial muscles
  • Flexion of upper extremities
  • Extension of lower extremities

38
Clonic
  • Resembles myoclonus
  • Loss of consciousness
  • Slower

39
Tonic-clonic
  • Extremely common
  • Begins suddenly without warning
  • Tonic contraction of the trunk
  • Rhythmic clonic contraction alternating with
    relaxation of all muscle groups
  • Marked increase in HR and BP
  • incontinence

40
Tonic-clonic
  • Seizure last 1 to 2 minutes
  • Post-ictal 30 minutes to 2 hours

41
Atonic Seizures
  • Suddenly dropping to the floor
  • Lanox-Gastaut syndrome
  • Can occur without LOC

42
Case 1
43
Case 1
  • 9-year-old boy
  • Parents were aroused one night by noise from his
    bed room
  • Noted bed sheets awry breathing deeply
  • bitten his tongue

44
Case 1
  • Confused
  • Afebrile

45
First Non-Febrile Seizure
46
History
  • Was this a true seizure or a non-epileptic event?

47
History
  • Circumstances
  • Normal activity vs. provoked
  • Upon awakening
  • Duration
  • Aura
  • Abnormal motor movements
  • Abnormal eye movements/automatism

48
History
  • Post-ictal period
  • Urinary or fecal incontinence
  • Fever, trauma or drug
  • Birth history
  • Delayed milestones
  • Family history of seizures

49
Physical Examination
  • Vital signs
  • Level of consciousness
  • Head circumference (percentile)

50
Always undress and examine the child
51
Café-au-lait spot
  • Uniformly hyper-pigmented
  • sharply demarcated macules
  • Normal children (1-3 spots)
  • 10 of normal children
  • May be present at birth or develop later

52
Neurofibromatosis (NF-1)
  • Six or more, 5 mm in prepubertal
  • Six or more, 15 mm in postpubertal
  • Crowe sign
  • freckled appearnace in axilla

53
Neurofibromatosis (NF-1)
  • Present in 100 of patients
  • present at birth
  • Increase in size, number pigmentation
  • Predilection for trunk extremities
  • Spare face

54
Lisch nodules
  • Pigmented hamartomas of the iris
  • NF-1
  • Prevalence increases with age
  • 5 (
  • 42 (3-4 years)
  • 100 (21 years)

55
Lisch nodules
  • Asymptomatic
  • Do not correlate with the extent severity
  • Do not occur in normal individuals
  • Best identified with slit lamp

56
Adenoma Sebaceum
  • Erythematous papules over nose malar areas
  • Develop between 4 and 6 years of age
  • coalesce assume fleshy appearance
  • Tuberous sclerosis

57
Ash-leaf spots
  • Hypo-pigmented
  • Irregular borders
  • May be present at birth
  • Detectable by 2 years in 50
  • Woods ultraviolet lamp

58
Shagreen patch
  • Roughened raised lesion
  • Orange-peel consistency
  • Primarily lumbo-sacral area

59
Tuberous Sclerosis
  • Infantile spasm
  • Hypsarrhythmic EEG pattern

60
CT Scan
  • Periventricular calcifications

61
MRI
  • Multiple cortical tubers

62
Port-wine stain
  • Macular cutaneous nevus
  • Present at birth
  • Always involves upper face eye lids
  • unilateral
  • Sturge-Weber Disease

63
Port-wine stain
  • Tonic clonic seizure contralateral to the side of
    facial nevus
  • Refractory to anticonvulsant
  • hemiparesis

64
CT Scan
  • Normal at birth
  • Gyriform contrast enhancement
  • Hemispheric atrophy
  • Parenchymal calcification
  • Railroad track

65
Physical Examination
  • Café-au-lait spots (NF)
  • Adenoma sebaceum (TS)
  • Facial hemangioma (Sturge-Weber)
  • Petechiae (meningitis)

66
Physical Examination
  • Hematoma or skull fractures
  • Signs of raised ICP
  • Retinal hemorrhages (Child abuse)
  • Signs of meningeal irritation

67
Diagnostic Evaluation
  • Bedside glucose
  • Serum Ca Mg (
  • Urine drug screen
  • CT head
  • Outpatient EEG

68
Rolandic Epilepsy
  • Benign Partial Epilepsy with Centrotemporal
    Spikes (BPEC)

69
Rolandic Epilepsy
  • Common in childhood
  • 2 - 14 years
  • Peak age 9 -10 years
  • Normal children
  • Unremarkable past history
  • Normal neurologic examination

70
Rolandic Epilepsy
  • Simple partial seizure
  • 3-13 years (peak 9-10 years)
  • Almost always at night (75 sleep)
  • EEG (centrotemporal spike)
  • Carbamazepine
  • Excellent prognosis
  • Spontaneous remission by age 15 year

71
Infantile Spasm (Wests synd)
  • Sudden jerks of group of muscles
  • 4-12 months
  • Characteristic EEG (hypsarrhythmia)
  • Poor prognosis
  • ACTH/Steroid

72
Case 2
73
Case 2
  • 7-month-old boy with runny nose and fever. His
    pediatrician saw him diagnosed URI. He received
    tylenol. On the same afternoon while sitting on
    his mothers lap he began to stare and had a
    generalized tonic-clonic seizure. The entire
    episode lasted approx 5 minutes

74
Case 2
  • He fell asleep after the seizure.
  • Normal development
  • T 102 F, HR 124, R 30 BP 90/50
  • Wt 7.9 Kg (50)
  • Ht 66.5 cm (50)
  • HC 44 cm (50)
  • No NC lesions

75
Febrile Seizures
76
Febrile seizures
  • Most common type of seizures in the pediatric age
  • usually benign
  • Can cause considerable parental anxiety

77
Febrile seizures
  • Seizures that occur in infancy or childhood
    usually occurring between 3 months and five
    years, associated with fever, but without
    evidence of intracranial infection or defined
    cause

78
Febrile Seizures
  • Age dependent
  • Rare before 9 months after 5 years
  • Peak age 9-20 months
  • Incidence 3 - 4
  • Family history
  • Diagnosis of exclusion

79
Febrile Seizures
  • Risk factors
  • Height of temperature
  • Male sex
  • Family history of febrile seizure

80
Febrile Seizures
  • A family history of epilepsy has not been shown
    to be a risk factor for first febrile seizures

81
Febrile Seizures
  • Risk factors for recurrence
  • Young age at onset
  • Febrile seizures in first degree relative
  • Lower degree of fever

82
Febrile Seizures
  • Generalized tonic-clonic
  • Duration few seconds to 10 minutes
  • Excellent prognosis
  • 20 are complex

83
Febrile Seizures
  • Complex febrile seizure
  • 15 minutes
  • More than once in 24 hours
  • Focal neurologic features

84
Febrile Seizures
  • Risk of recurrence 34
  • Most recurrences within 6-12 months

85
Lumbar Puncture
  • The decision to perform LP should be based on the
    age of the child at presentation (AAP)

86
Lumbar Puncture
  • Strongly recommend
  • 12 - 18 months
  • Should consider
  • 18 months
  • If history physical examination suggest
    intracranial infection

87
Febrile Seizures
  • Signs of meningeal irritation
  • Unreliable under 18 months

88
Red flags
  • Focal seizure
  • Suspicious physical examination findings (eg,
    rash, petechiae) cyanosis, hypotension, or
    grunting
  • Abnormal neurologic examination

89
Febrile Seizures
  • Meningitis must be ruled out
  • Difficult if the patient is on antibiotics

90
Febrile Seizures
  • Determine and treat the cause of fever
  • IV benzodiazepine
  • Rectal diazepam
  • No routine AED prophylaxis

91
Febrile Seizures
  • Incidence of epilepsy
  • 1 (No other risk factor)
  • 9 (Other risk factors)

92
Epilepsy
  • Family history of later epilepsy
  • Preexisting neurologic abnormality
  • Complex febrile seizure
  • 15 minutes duration
  • 1 febrile seizure per 24 hour
  • Focal febrile seizure

93
Neonatal Seizures
94
Neonatal Seizures
  • Seizures during first 28 days
  • 0.5 of all live births
  • Do not indicate epilepsy

95
Jitteriness Vs Seizure
  • Movements are stimulus sensitive
  • Appear during active state (crying)
  • Disappear on passive flexion
  • Not jerky
  • No abnormal eye movements

96
Neonatal Seizures
  • Neonates are at particular risk
  • Metabolic
  • Toxic
  • Structural
  • Infectious

97
Neonatal Seizures
  • Not generalized tonic-clonic
  • incomplete myelination
  • Can be very subtle
  • Minimal physical findings

98
Neonatal Seizures
  • Subtle
  • Tonic
  • Clonic
  • Myoclonic

99
Subtle Seizure
  • More common in premature infants
  • Eye deviation jerking
  • eyelid blinking
  • fluttering
  • smacking or drooling
  • Apneic spells

100
Causes
  • Perinatal asphyxia
  • Intracranial hemorrhage
  • Metabolic - hypoglycemia, hypocalcemia
  • Infections
  • Drug withdrawl

101
History
  • Family history
  • metabolic
  • Maternal drug history
  • Delivery
  • Mode nature of delivery
  • Fetal intrapartum status
  • Resuscitative measures

102
Physical Examination
  • Gestational age
  • Blood pressure
  • Presence of skin lesions
  • Presence of hepatosplenomegaly
  • Neurologic evaluation

103
Lab
  • Serum chemistry
  • Spinal fluid
  • Metabolic work-up
  • serum ammonia
  • amino-acids

104
Lab
  • Head sonogram
  • IVH/periventricular
  • CT head
  • Hemorrhage
  • Calcifications
  • Malformations
  • EEG

105
Management
  • The method of treatment depends on the cause
  • Anticonvulsant
  • Phenobarbital

106
Status Epilepticus
107
Status Epilepticus
  • Seizure 30 minutes
  • Intermittent seizures longer than 30 minutes from
    which the patient does not regain consciousness

108
Status Epilepticus (SE)
  • Highest incidence in very young children
  • 5 of ED visit of seizing children
  • 70 of children with epilepsy experience at least
    one episode of SE
  • Mortality rate 8 to 32

109
Status Epilepticus (SE)
  • Any type of seizure
  • Generalized (most common)
  • Absence or partial (10)
  • Febrile SE (25)

110
Life-threatening causes
  • Bacterial meningitis
  • Hypoglycemia
  • Increased intra-cranial pressure
  • Hypoxemia
  • Toxins
  • TCA, Cocaine, Theophylline, insulin

111
Management
  • Rapid stabilization of cardio-respiratory
    functions
  • Termination of both clinical electrical
    seizures
  • Diagnosis treatment of life threatening
    precipitant

112
Status Epilepticus
  • The child is often given too much IV
    benzodiazepine.Blood gases are measured and
    perhaps the values are found to be slightly
    decreased. The child is then paralyzed,
    intubated, and sent to the intensive care unit to
    recover from the iatrogenic morbidity.

113
Status Epilepticus
  • Freeman JM Status epilepticus Its not what
    weve thought or taught. Pediatrics
    198983444-445

114
Status Epilepticus
  • Primary goal is to stop the seizure
  • First line (benzodiazepine)
  • Second line (phenytoin or fosphenytoin)

115
Diazepam
  • Rapid onset (3 - 5 minutes)
  • Orally, IV, IM, IO or Rectal
  • Duration of action 20 - 30 minutes
  • Respiratory depression, sedation, hypotension
  • Diastat (rectal gel)

116
Diazepam
  • IV 0.1 - 0.5 mg/kg
  • Rectal 0.2 - 2 mg/kg
    (maximum 10 mg)

117
Lorazepam
  • Slower onset
  • Longer duration (12 - 24 hours)
  • Orally IV
  • Inappropriate for rectal administration
  • 0.05 - 0.2 mg/kg
  • Must be refrigerated
  • Tachyphylaxis

118
Phenobarbital
  • Long duration (24 hours)
  • IV 10-20 mg/kg bolus
    rate 1-2 mg/kg/min
  • Intubation (30-40 mg/kg)
  • Respiratory depression, hypotension bradycardia

119
Phenytoin
  • 1950 - Massachusetts General Hospital
    pH 12, limited solubility in water Propylene
    glycol ethanol
  • 1956 - Parenteral formulation approved
  • 1962 - pediatric dose recommendation
  • 1986 - Revised Pediatric dose
    (15-20 mg/kg, 1-3 mg/kg/min)

120
Phenytoin
  • High pH
  • Burning cutaneous reactions
  • Purple glove syndrome

121
Phenytoin
  • Propylene glycol
  • Seizures
  • Arrhythmia
  • Asystole
  • Hepatic renal damage
  • Hemolysis
  • Hyperosmolality
  • Lactic acidosis

122
Phenytoin
  • The amount of propylene glycol in a typical
    loading dose of phenytoin administered to a 1 kg
    premature neonate is about seven times greater
    than WHO standard

123
Fosphenytoin 1996
  • Pro-drug of phenytoin
  • pH 8
  • Far more soluble in water
  • No organic solvent
  • Both IV IM
  • Rapid complete conversion to phenytoin

124
Sports Participation
125
Sports Participation
  • Unnecessary restrictions
  • Successful athelete with epilepsy
  • Gary Howatt (hockey player)

126
Sports Participation
  • Which sport
  • Common sense
  • Significant metabolic imbalance
  • Scuba diving
  • Potential for serious injury

127
AMA Committee for Sports
  • Patients with epilepsy will not be affected by
    indulging in any sport, including football,
    provided the normal safegaurds for sports
    participation are followed, including adequate
    head protection

128
Permitted Sports
  • Baseball
  • basketball
  • broad jumping
  • hockey
  • gymnastic
  • Soccer
  • wrestling

129
Reasonable precautions
  • Bicycling
  • Diving
  • Football
  • Skating
  • Swimming

130
Prohibited Sports
  • Boxing
  • Bungee jumping
  • Polo
  • Scuba diving
  • Skydiving
  • Waterskiing

131
Driving Regulatory Issues
132
Driver Licensing
  • Each state has its own regulations
  • Seizure free period
  • 1 Year (NY)

133
Reporting responsibility
  • Patient responsibility (most states)
  • Physician responsibility (Six states)
  • CA, DE, NE NJ, OR, PA

134
Employment
135
Employment
  • Average intelligence
  • Good health
  • Unpredictable loss of consciousness

136
Employment
  • No hard-and-fast rules
  • Should avoid workplaces in which a sudden loss of
    consciousness may expose them or their coworkers
    to risk or injury

137
Employment
  • Interstate truck
  • Forklift
  • Working in heights

138
Pregnancy Epilepsy
139
Pregnancy Epilepsy
  • 20,000 births women with epilepsy
  • Lower seizure threshold

140
Offspring AED
141
Offspring AED
  • Pheytoin
  • fetal hydantoin syndrome
  • Valproate
  • neural tube defect
  • Carbamazepine
  • spina bifida

142
Labor Delivery
143
Labor Delivery
  • Bleeding tendency in neonate
  • induction of hepatic enzymes
  • overcome by Vitamin K

144
Breast feeding AED
145
Breast feeding AED
  • Nearly all epileptic drugs are transferred in
    breast milk
  • Phenytoin 18
  • Phenobarbital 36
  • Carbamazepine 41
  • Valproate 5
  • Breast feeding is not contraindicated

146
Oral contraceptives AED
147
Oral contraceptives AED
  • Increase the dose of Oral contraceptives
    (AED induces hepatic metabolism of hormones)

148
Dont forget child abuse
  • Discrepancy between history injury

149
You are mandated by law to protect these
children
150
Its not optional
  • New York State Law (Social Services Law Section
    413) requires that any health professional who
    suspects that a child is being endangered or
    maltreated must report his/her suspicion to NY
    City, to the local child protection services

151
New AEDs
152
New AEDs
  • Gabapentin (Neurontin)
  • Lamotrigine (Lamictal)
  • Vigabatrin (Sabril)
  • Felbamate (Felbatol)

153
Take home message
  • Wide range of presentation
  • Efficiently obtain information
  • Always undress examine
  • Establish underlying etiology
  • Suspect abuse with inconsistent history
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