Approach to patient with convulsion

Approach to

Patient with

Convulsion

Presented by: Ali Abdullah

Supervised by: Dr. Aso

University of Sulaimani

Faculty of Medical

Sciences

School of Medicine

DefinitionSeizure: Is a paroxysmal event due to transient, abnormal, excessive, hyper-synchronous discharges from an aggregate of CNS neurons; characterized by disturbance in muscle tone, posture, sensation, consciousness, or psychological state.

Convulsion: Is seizure with abnormal movement.

Epilepsy: syndrome due to recurrent unprovoked seizures; it’s diagnosed when there are two or more unprovoked seizures due to a chronic, underlying process.

Approach: Ideas or actions intended to deal with a problem or situation. “WordWeb dictionary”

Classification of Seizure

This is essential for diagnosis, therapy, and prognosis.

Focal S. Vs. generalized S.

Febrile S. Vs. non febrile S.

Epileptic S. Vs. non epileptic S.

True S. Vs. pseudo S.

Classification of SeizureS

eiz

ure

Partial

Simple partial

Complex partial

Partial with 2o Generalization

1o Generalized

Convulsive

Tonic clonic (grand-mal)

Tonic S.

Clonic S.

Non-Convulsive

Absence (petit-mal)

Myoclonic

Atonic

UnclassifiedNeonatal seizure

Infantile spasm

ApproachHistory

Examination

Investigation: early

Acute Rx.: Non-specific

Acute Rx.: Specific

Investigation: further

Long term Rx.

ApproachHistory from and description by an eye witness is the main line of diagnosis.

History of the patient about seizure manifestations may give clue about type and location of the seizure focus.

Questions:- Whether, it’s initial onset, or he/she had attacks which was overlooked by the parents?

- Nature and pattern (clustering) of the attack.

- Precipitating factor: (sleep or sleep deprivation, TV, stress, mental activity) or exacerbations.

- Frequency, duration and time of occurrence.

- History of personality change or symptoms of raised ICP intracranial tumor; versus history of cognitive regression degenerative or metabolic disorder.

- Certain medications such as CNS stimulants and antihistamines.

- History of prenatal and perinatal distress or developmental delay cong. Or perinatal brain dysfunction

- Including family history of epilepsy and febrile convulsion.

- History of postictal period.

ApproachHistory :Age may lead you to the cause or even the type of the seizure:– Neonate (<1 month): Hypoxia, CNS infection, metabolic, drug withdrawal,

developmental and genetic disorders. – Infants and children (<12 years): Febrile, genetic, CNS infection, trauma and

idiopathic. – Adolescent and young adults (13-35): Trauma, alcohol withdrawal, drugs,

tumor, idiopathic. – Older adults (>35): Cerebrovascular disease (50%), tumor, alcohol withdrawal,

metabolic, Idiopathic.

Abnormal movements:o Present: Grand-mal, Tonic, Clonic, ...o Absent: petit-mal, atonic, …

Eye rolling: Absence of eye rolling increase suspicion of non-convulsive causes of LOC.

Duration: significance and even type of the attack.

Physical Examination:General exam includes:– Vital signs and respiratory and cardiac function.– Search for signs of infection, trauma, toxins, systemic illness,

neurocutaneous abnormalities, vascular disease and drugs.

Asymmetries in neurologic exam suggest brain tumor, stroke, trauma, or other focal lesions.

Skin exam for pigmented or de-pigmented spots .

Approach

Investigations:Laboratory Evaluation:

Blood exam: for CBC, electrolytes, serum glucose, liver and renal function, urinalysis, toxicology screen and culture.

Lumbar puncture: indicated if suspicion of CNS infection (when meningeal signs present), mandatory in HIV-infected patients.

Approach

Acute Management:A. Non-Specific:

Admission

Positioning: Semi prone with head to side to avoid aspiration

ABC and normalization of vital signs- Tongue blades should not be forced between clenched teeth- Oxygen should be given via face mask.

Blood taken for: RBS, CBC, electrolyte, urea, Cr, lactate, anticonvulsant level

Reversible metabolic disorders (suspected or proofed) such as: (hypoglycemia, hypo/hyper natraemia, hypocalcaemia, drug or alcohol withdrawal) should be corrected.

Approach

Acute Management:B. Specific: Anticonvulsant therapy

* When to START …?1. Diazepam 0.2-0.3mg/kg IV slowly; if not responds, repeat after 10

minutes; then if not responds …

2. Phenobarbital or phenytoin 10-20 mg/kg; if not responds, repeat after 10 minutes; then if not responds …

3. Diazepam infusion, IV medazolam

4. IV Valproic acid

5. GA by pentothal, halothane with muscle relaxant under ventilator.

C. Further investigations to detect the cause: … …

Approach

Approach

Investigations:• EEG: All patients should have it as soon as possible; Ictal, postictal

abnormality, spikes and waves especially for epileptic seizures, with provocation by photo stimulation, sleep induction, hyperventilation. Presence of electrographic seizure esp. during seizure attacks establish the diagnosis, But negative EEG does not exclude diagnosis of seizure.

• E.E.G. with simultaneous closed video-recording: can provide information which rarely records during routine E.E.G.

• Neuro-imaging CT scan & MRI: in unexplained new onset seizure, but not used routinely.

Approach

Differential Diagnosis: Includes a long list, but the main DDx. are syncope and pseudo-seizure:

1. Breath holding attacks.

2. GERD (sandifire syndrome).

3. Infantile colic.

4. Temper tantrum.

5. Masturbation in female toddlers.

6. Hysterical (conversional disorder).

7. Tics.

8. Others ……

Long term therapy includes:- treatment of underlying condition- avoidance of precipitating factors- prophylaxis with antiepileptic therapy - or surgery, - and even addressing various psychological and social issues.

Choice of anti epileptic medication based on different factors including: - Age and sex- type of seizure- dosing schedule - and potential side-effects.

Therapeutic goal:– complete cessation of seizures– With minimal side effects– Using single medication (mono-therapy)– Dosing schedule that’s easy for the pt. to follow

Approach

Start Low, Go Slow

If ineffective, medication should be increased to maximal tolerated dose based primarily on clinical response rather than serum level.

If unsuccessful, second drug should be added, when control achieved, the first drug can be slowly tapered.

Some may require poly-therapy

Certain epilepsy syndromes (e.g.: temporal lobe epilepsy) are often refractory to medical Rx. and benefits from surgical excision of the epileptic focus.

Approach

Selection of antiepileptic drugs:

Status EpilepticusClassical definition:

- continuous seizure activity

- or two or more seizures

- in 30 minutes without recovery of consciousness.

Controversial new definition: - more than 5 minutes of seizure activity

- or two or more seizures without recovery of consciousness.

• Status epilepticus is the most disastrous attack of seizure on the

whole life of the baby if not treated early.

• A neurological emergency with 10-20% mortality

• Treatment protocol of Status epilepticus is crucial even the timings.

Status EpilepticusSE may be Convulsive with tonic/clonic movements or Non-

Convulsive with LOC and often subtle twitching.

Non-Convulsive SE is diagnosed by EEG, and suspected in comatose.

Common causes of childhood SE:

(fever, sub-theraputic anticonvulsant Rx., CNS infection, trauma,

poisoning and metabolic abnormalities)

Investigations:

Status EpilepticusTime bounded algorithm for management of SE; this can be started once a

convulsive seizure has lasted more than 5 minutes:

A. 0-5 minutes: ABC Establish IV access. Monitor vital signs (esp. pulse oximetry) Give 100% Oxygen via mask.

B. 5-15 minutes: Start anticonvulsant IV lorazepam (50-100mcg/kg, up to 4mg); Or Rectal diazepam (0.5mg/kg, up to 10mg) If no response, repeat after 5-10 minutes

C. 15-35 minutes: if persists IV phenytoin (15-20mg/kg, rate <1mg/kg/min) IV Phenobarbital (15-20mg/kg, rate <1mg/kg/min)

Status EpilepticusD. 45 minutes: Refractory seizure

IV phenytoin or phenobarbital (whichever was not given) Additional phenobarbital (5mg/kg/dose, every 30min. to

maximum of 30mg/kg can be used)

If seizure stops, continue with maintenance phenytoin (IV/oral/via NG)

Refractory seizure: Intensive care: If seizure persists, intensive care should be initiated Intubate the trachea and support breathing Intensive care medications include midazolam and thiopentone EEG monitoring

PrognosisGenerally excellent:

• Idiopathic• Hypocalcemia• Benign familial neonatal seizure• Fifth-day fit

Significant risk of adverse neurodevelopmental outcome• Meningitis• HIE grade II• Hypoglycemia• Cerebral infarction• Hyper/hypo natremia• Drug withdrawal

High risk:• HIE grade III• Cerebral malformation• Kernicterus• Some IEM

PrognosisPrognosis with drug treatment (long term):

By 12 months, 60-70% will be seizure free. After 2 years of seizure-free period, withdrawal of drugs can be considered.

Predictive factors for relapse:

• Syndromic epilepsy

• Underlying structural pathology

• Severe prolonged epilepsy before remission

• Increased age