Seizures in Childhood CME November 2-4, 2013 Dr. Lumphoon.

Seizures in Childhood

CME November 2-4, 2013Dr. Lumphoon

Pre-Test

1) What is the most common cause of childhood seizures?

a) poisoning b) birth trauma c) fever d) head trauma

Pre-test

2) What drug should you use to stop a seizure that has lasted 4 minutes?

a) phenobarbital

b) diazepam c) phenytoin d) don’t treat unless seizure has lasted at

least five minutes

Pre-test

3) When a child has a seizure, when is a lumbar puncture indicated?

a) In every case

b) Only if there are signs of increase intracranial pressure

c) If there is fever and neck stiffness, and meningitis is being

considered d) If the child has a red throat

Pre-test

4) What is the first thing you do when confronted by a seizing patient?

a) ABC’s , recovery position, glucose b) Draw blood for electrolytes and

glucose c) Administer bicarbonate to counteract

metabolic acidosis d) Observe to see how long the seizure is

going to last

Pre-test

5) What is the most important part of chronic seizure management in children?

a) Use of two medications for seizure control

b) Discovering the family’s knowledge level and educating them as much as possible about the seizures and what to do.

c) CT scan of the brain d) Educate the community about the

seizures e) b and d

Seizure Definition

• Transient, paroxysmal, involuntary events characterized by alterations of consciousness, behavior, motor skills, autonomic activity, or sensation.

• Results from abnormal, involuntary rhythmic discharges from a group of neurons in the brain.

• A seizure is a sign of underlying disease, not a disease itself.

Status Epilepticus

• Status epilepticus involves continuous seizure activity or intermittent seizure activity without full recovery for a period of 30 minutes or longer.

• Status epilepticus is an emergency. • These seizures need to be stopped, and the

etiology needs to be addressed to avoid neurological damage.

Epilepsy

• The term ”epilepsy” refers to that state of susceptibility of a child or adult to recurrent seizures.

Case 1

• Noy is a 3- year old girl who presents to your clinic with a history of fever for two days. She now has had a seizure which first occurred this morning.

• Noy is accompanied by her grandfather.

Case 1

• Noy is sleeping comfortably in grandfather’s lap and appears stable.

• What questions do you need to ask her

grandfather about the seizures?

Case 1

• WWQQAAAB• Where• When • Quantity• Quality• Aggravating factors• Alleviating factors• Associated factors• Belief about symptoms

Short differential

• What is your short differential diagnosis?

Case 1

• What other relevant history do you request?

Case 1• Past Medical History: Previous seizures, prematurity,

prenatal, intrapartum or neonatal problems• Development: Past development, any regression.• Family History of seizures, epilepsy (higher occurrence

of both with positive family Hx)• Social History: Why has her grandfather brought her?• Immunization status• Medication• Allergies• Pets, Travel• Review of Systems

Case 1

• Noy has been previously healthy. Normal development so far. Her grandfather doesn’t think she has had any immunizations yet.

• One of Noy’s teenage sisters has had seizures intermittently since she was a 2 year old.

• Noy lives with her grandfather because both her parents died “in an accident”.

Case 1

• What is your problem list?

• Is there any change to your differential diagnosis ?

• May use VITAMIN CDP to generate a larger Differential Diagnosis.

Case 1

• Just as you prepare to do a physical exam, Noy stiffens in all limbs, her eyes roll back and she begins shaking rhythmically.

Case 1

• What do you think is happening?

• What do you do?

Case 1

• It seems like Noy is having a seizure but you need to distinguish seizure from jitteriness or rigors/chills

• You cannot stop a limb which is seizing by holding it (this trick is especially useful in neonates)

• Level of consciousness will be impaired if this is a generalized tonic-clonic seizure

Case 1

• You have decided this is most likely a febrile seizure.

• What do you do now?

DO

•ABC’s-recovery position, put nothing in mouth unless it is for the airway, clear vomitus, jaw thrust if necessary.

•O2 if needed (usually don’t need this, so it does not need to be a priority)

DO

• Assess for shock / dehydration• Check glucose OR consider empiric dextrose-

D50- treatment if no testing kit available

DO

• Assess—don’t panic—only treat with medication if seizure lasts >5 min.

• Note if there are any localizing features

• You are once again prepared to do a physical exam. What are the most important things to do and document?

Physical exam

• Vital signs, Head Circumference• Level of consciousness. • Pupils and Cranial Nerves for palsy. • Fundoscopy for papilledema (discuss risks

associated with raised ICP). • Meningeal signs are critical. • Any focal neurological findings (need to

document tone, reflexes, Babinski).

Physical exam

• Pallor and cardiac gallop (malaria) • Petechiae (meningitis) • Spleen and liver enlarged?

Case 1

• Noy has a temperature of 40.2oC. HR 120. RR 28. You notice a II/VI systolic ejection murmur along the left sternal border. There is no gallop and she is not pale.

• She has not had another seizure

• What do you think about the murmur?

Case 1

• Heart murmurs—this is most likely a benign flow murmur especially common in thin children with fevers (to be sure, you must check again when fever has gone down).

DDx

• Prepare a differential diagnosis for seizures in a patient such as Noy based on what you know.

• Comment on differentiating features.

Differential Diagnosis• Febrile convulsion secondary to infection (viral, bacterial or malaria)• Meningitis• Cerebral Malaria• Seizure secondary to hypoglycemia (and possibly malaria)• encephalitis, • trauma, • stroke/hemorrhage,• poisoning• metabolic encephalopathy, • neurodegenerative disorder, • brain tumor, neurocutaneous syndrome

• What is your problem list ?

Problem list

• Acute febrile seizure• ? Infection—malaria vs meningitis vs other• Not immunized• Need for family counseling, what to do if

siezure recurs• Heart murmur• Orphaned• Family history of non febrile seizure

• Which investigations would you consider?

Investigations

• Laboratory tests (such as CBC, Na+, K+, Ca++, Mg++, glucose, and P04) depend on the symptoms, seizure type, and history… if no history of fever, must consider electrolytes

• If a seizing febrile child has had several episodes of vomiting and diarrhea, check electrolytes, just as if the child had seized without fever.

• In the case of simple febrile seizures, routine laboratory tests are usually not indicated.

Investigations

• The literature for tests for complex febrile seizures is not as clear as those for simple febrile seizures.

• Do consider laboratory tests in children who present with complex febrile seizures.

• A child with fever may also have a known seizure disorder, so check seizure medication levels.

Fever without an obvious source

• Obtain a CBC and blood cultures• Catheterized urine for urinalysis and urine

culture • Stool culture for bacterial or viral enteric

infection, and shigellosis• Nasal swabs for respiratory syncytial virus

(RSV) or influenza, if appropriate.

What about a lumbar puncture?

Indicators For Lumbar Puncture For Evaluation Of Pediatric Febrile Seizure

• Recent doctor (or health care provider) visit for febrile illness

• Less than 12 months of age*• 12 months to 18 months of age*• Altered mental status• Prolonged post-ictal period

* If the child returns to normal (ie, normal neurological examination, appears happy, nontoxic, etc.) in a case where meningitis is considered unlikely, some literature suggests that an LP is not strongly indicated in the routine evaluation of a febrile seizure

Indicators For Lumbar Puncture For Evaluation Of Pediatric Febrile Seizure

• Signs of increased intracranial pressure (ie, bulging fontanelle)-if considering meningitis

• Kernig’s or Brudzinski’s sign• Increased irritability• Petechiae• Recurrent seizures, seizures in the Emerg Dept• Recent antibiotics

Case 1

• Prepare a brief treatment plan based on your problem list

Case 1

• Airway• Breathing (O2 if necessary)• IV access for hydration, • Antipyretic: acetominophen• Bloodwork (glucose, Na, K, CBC, blood cultures,

urinalysis, urine culture)• Antibiotic (+/- steroids)• + / - LP• ? Antimalarials

• Noy recovers thanks to your fine management

• Discuss what information you will give her grandfather : chance of recurrence, what to do at home, when to bring her to hospital again

Facts: Febrile Seizures

• 3mo - 5yr• Single, brief, occurs during rapid rise of fever

>38C, but without evidence of intracranial infection or defined cause

• Generalized seizure / Not focal• Normal child neurologically both before and

after seizure

Facts: Febrile Seizures

• Called “complex” febrile seizure if lasts longer than 15min, is focal, or recurs within 24h (although this seems common with malaria)

• Complex seizures have an increased risk of meningitis (9%), compared to simple febrile seizure (3%)

• Many children will have a positive family history of febrile seizure and recurrence is high (about 1/3)

Facts: Febrile Seizures

• There is no strong evidence that giving antipyretics in the absence of Anti Epilepsy Drugs (AED) can prevent recurrent febrile seizures.

• AEDs are not routinely recommended for the chronic prevention of febrile seizures.

Facts: Febrile Seizures

• Children with febrile seizures have only a 1-2% chance of developing lifetime epilepsy, compared to only a 0.5 - 1% risk in other children

• Unless there are 2 or more risk factors (such as family history of epilepsy, neurological condition or disorder, or complex seizure), then the risk for epilepsy jumps to 10%

Facts: Febrile Seizures

• 33% of children who experience a febrile seizure will experience a second febrile seizure

• Peak incidence of febrile seizures occurs at about 18 months of age

Case 2

• A 4-year old boy is brought to see you by his parents. 5 minutes ago he started having a generalized tonic- clonic seizure. There was no preceding trauma. Prior to the seizure, the parents describe that the boy was vomiting and was talking funny.

Case 2

• On exam the boy is having a generalized tonic clonic seizure. He is not responding to verbal or painful stimulation.

• HR 140, BP 70/40, RR 20, O2 sats 96%. His temperature is 37.8C.

• His pupils are dilated bilaterally and reactive to light. He is hyper-reflexic. Normal cardiovascular, respiratory and abdominal exam.

DO

•ABC’s-recovery position, put nothing in mouth unless it is an airway, clear vomitus, jaw thrust if necessary.

•O2 if needed (usually don’t need, so this does not need be a priority)

How would you manage this child?

Manage seizure once ABC’s taken care of

DO

• Assess for shock / dehydration• Check glucose OR consider empiric dextrose-

D50- treatment, if no testing kit available

Management

• Check chemstrip….BG 12• IV fluid bolus• Treat the seizure

DO

• Diazepam 0.3 mg/kg IV. May be given x 3 doses, 5 minutes apart if seizure not subsiding, maximum per dose 10 mg

• Per Rectum(PR) Child 2 - 5 years: 0.5 mg/kg• PR-Child 6 - 11 years: 0.3 mg/kg• PR-Child > 12 years: 0.2 mg/kg, maximum per

dose 20mg • The rectal route is useful when intravenous

access is unavailable.

DO

• Consider Phenytoin or Phenobarbital load (Some prefer Phenytoin because less depression of consciousness and less likely to cause respiratory depression in combination with diazepam, but difficult to attain therapeutic levels)

• Loading dose Phenobarbital and Phenytoin (10-15mg/kg) if seizure persisting

DO

• Watch carefully for respiratory depression which can happen with either drug alone or especially with the combination of diazepam and phenobarbital

• Check blood electrolytes, glucose, CBC

Case 2

• The child’s seizure stops but he is still obtunded and does not respond to stimulation

• After 15 minutes, he has another seizure

What would you do now?

Case 2

• Recheck vitals

• Retreat as above

Differential Diagnosis

• What could be the cause of this child’s seizures?

Differential Diagnosis

• Idiopathic• Meningitis• Cerebral malaria• Febrile convulsions• Hypoglycemia• Hyponatremia• Head injury• Brain tumor• Poisoning• Shock

Case 2

• Once you have the seizures under control, you must talk to the parents.

• They tell you this is the third time the child has had seizures in the past 3 months.

• What advice do you give them now?

Epilepsy

• Tell them their child likely has Epilepsy—most often begins in childhood

• Risk factors include previous seizure (febrile or non), family history, cerebral palsy

• If a child has 2 or more unprovoked seizures or 1 unprovoked seizure with an abnormal EEG, then a definition of epilepsy can be made and appropriate Anti-Epilepsy Drugs started

Epilepsy

• Is a diagnosis of exclusion or pattern recognition—rule out brain tumour, infection, injury, neurocutaneous disease, syncope, hypoglycemia, hypocalcemia, breath-holding spells, drug-induced movement disorder.

• An EEG would be the best test to do in a normally developing child.

• If the child had abnormal development, you might consider imaging the brain, if it is available.

Epilepsy

• Medication is required if there are recurrent seizures

• Phenytoin or Phenobarbital are the usual medications used first

• Both have side effects• There are many new seizure medications now.

May not be available in Laos, or affordable.

Epilepsy

• Seizure management at home:- Don’t panic- Place in recovery position to avoid aspiration- Place nothing in mouth. - Bring to medical attention if seizure is persistent (>15 min) or if frequency increases

Epilepsy

• Risk of mortality by drowning (while swimming or bathing) and burns (falling into fires)—therefore child must be carefully supervised.

• Keep all antiepileptic drugs in a safe place.• May discuss stigma of epilepsy—school,

community, traditional beliefs• ***see appendices for more information

Case 3

• An 11-month old presents to your emergency room. He has been seizing for 30 minutes, generalized tonic- clonic movements. He is slightly cyanosed and unresponsive.

• The nurse puts him on a bed on his back, and leaves the room, telling his parents to watch him.

• She finds the doctor and tells him there is a sick child in the room, then leaves to eat.

Case 3

• The doctor finishes his chart, then goes to the room to find the child in a pool of vomit, choking, and very blue.

• His parents say they are afraid to touch him, because the nurse told them to watch him.

Case 3

• What do you do now?

Case 3

• What steps could be taken in your hospital/office to ensure better care of this kind of patient in the future?

Pre-Test

1) What is the most common cause of childhood seizures?

a) poisoning b) birth trauma c) fever d) head trauma

Pre-test

2) What drug should you use to stop a seizure that has lasted 4 minutes?

a) phenobarbital b) diazepam c) phenytoin d) don’t treat unless seizure has lasted at least

five minutes

Pre-test

3) When a child has a seizure, when is a lumbar puncture indicated?

a) In every case b) Only if there are signs of increased intracranial

pressure c) If there is fever and neck stiffness, and

meningitis is being considered. d) If the child has a red throat

Pre-test

4) What is the first thing you do when confronted by a seizing patient?

a) ABC’s , recovery position, glucose b) Draw blood for electrolytes and glucose c) Administer bicarbonate to counteract

metabolic acidosis d) Observe to see how long the seizure is going

to last

Pre-test

5) What is the most important part of chronic seizure management in children?

a) Use of two medications for seizure control b) Discovering the family’s knowledge level and

educating them as much as possible about the seizures and what to do.

c) CT scan of the brain d) Educate the community about the seizures e) b and d

Appendices

• Information about seizures

Seizure types

• Seizures can be divided into generalized or partial types.

Generalized seizures

• Generalized seizures are associated with the involvement of both cerebral hemispheres and can be convulsive or nonconvulsive.

• Motor involvement, if present, is most often bilateral.

• An altered level of consciousness can be present with generalized seizures

Partial seizures

• Partial seizures can be simple or complex. • A partial seizure is defined as a focal event.• Simple partial seizures result in no impairment

of consciousness; clinical localization of epileptic focus is possible.

• The twitching of an arm in an awake patient is an example of a simple partial seizure.

Complex Seizures

• A complex seizure is a partial seizure associated with loss of consciousness.

• Complex seizures can be preceded by an aura and are associated with certain automatisms (patient is not aware of his surroundings while doing some unusual movements ).

• In 30% of children with either simple or complex partial seizures, the child can progress to having generalized seizures.

Special Seizures

• Febrile Seizures• Neonatal seizures• Infantile Spasms• Autonomic Seizures• Lennox Gastaut Syndrome• Benign Rolandic epilepsy

Epidemiology

• Childhood seizures are common (4-6% of children)

• Seizure is a symptom of an underlying disorder, not a disease in itself

• Fever is the most common cause of a seizure in a child.

Medications Used For Acute Seizure Management

Medication Suggested DosesDiazepam IV 0.3 mg/kg, maximum per dose 10mg PR Child 2 - 5 years 0.5 mg/kg PR Child 6 - 11 years 0.3 mg/kg PR Child > 12 years 0.2 mg/kg, max /dose 20 mg Lorazepam IV 0.05 – 0.1 mg/kg, maximum per dose 4 mg IM 0.05 – 0.1 mg/kg, maximum per dose 4 mg

Midazolam IV 0.15 to 0.2 mg/kg, followed by 0.5 –5mcg/kg/min continuous infusion

Buccal 0.2 – 0.3 mg/kg Intranasal 0.2 mg/kg

Medications used for Acute Seizure Management

Phenytoin IV 15 – 20 mg/kgFosphenytoin IV 15 – 20 mg PE/kg IM 15 – 20 mg/kgPhenobarbital IV 20 mg/kgPentobarbital IV 5 – 15 mg/kg, followed by 0.5 – 5

mg/kg/h continuous infusion

Valproic acid IV 20 – 40 mg/kg Levetiracetam IV 20 – 115 mg/kg/dayPropofol IV 1 – 2 mg/kg followed by 1 – 2 mg/kg/h

continuous infusion titrated to burst

suppression on the EEG

VITAMIN C,D,P

V vascular, hematologicI infectious, inflammatory, intoxicationT trauma, toxinA allergicM metabolic, endocrineI immunologic, autoimmuneN neoplastic, neurologic, nutritionC congenital, geneticD degenerative, drugsP psychiatric

Poisonings that can cause seizures

• ASA (aspirin)• INH (isoniazid)• Tricyclic antidepressants• Propranolol• Lithium• Hydrocarbons (camphor, toluene, phenols,

chlorinated)• Antihistamines