Pediatric Seizures Muhammad Waseem, MD Emergency Medicine Lincoln Hospital.

Pediatric Seizures

Muhammad Waseem, MDMuhammad Waseem, MD

Emergency MedicineEmergency Medicine

Lincoln HospitalLincoln Hospital

Few things are more frightening to parents than to witness their child having a seizure

Objectives Wide spectrum of Pediatric seizure Etiologies specific to children Treatment modalities in children Quality of life issues Legal implications

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

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

setting

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

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

Seizure Fit Spell Attack Convulsion

What is Seizure?

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.

Convulsion A seizure with prominent motor

manifestation

Epilepsy Disorder of CNS whose symptoms

are seizures Recurrent seizures Unprovoked

Seizure Most seizures are not epileptic Non-epileptic seizures are

physiologic Hypoxia Fever Toxins

Seizure Seizure is a symptom of a disorder

that need further investigations Does not constitute a diagnosis May occur in both normal &

abnormal tissue

Non-epileptic Events

Mimic Seizures Breath-holding spells Syncope Migraine Tics Night terror Pseudo-seizures

Non-epileptic Events Inaccurate diagnoses Inappropriate use of AED

Non-epileptic Events

Careful history

Breath-holding spells Frightening 6 months - 4 years Inciting event-Shrill cry-Breath

holding-Cyanosis Disappear spontaneously before

school age

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

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

attack on request

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

Seizure First step in identifying the

epileptic syndrome is correctly identifying the type of seizure

Why Should I know type of Seizure?

Seizure Clue to cause Appropriate treatment Prognosis

Epileptic Seizures Partial (40%) Generalized Unclassified

Partial Seizure Simple Partial Complex Partial Partial with secondary

generalization

Generalized Convulsive Non convulsive

Absence Seizure

Generalized- Convulsive Myoclonic Clonic Tonic Tonic-clonic Atonic

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

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)

Complex Partial Seizures (CPS) Dystonic posturing, tonic or clonic

movement Postictal phase Duration 1 - 2 minutes Usually during waking hours

Absence Seizure Sudden cessation of motor activity

or speech Blank facial expression Flickering of eye lids

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

Absence Seizure Hyperventilation induces an

absence seizure 3/sec spike on EEG

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

Tonic Tonic spasms of truncal & facial

muscles Flexion of upper extremities Extension of lower extremities

Clonic Resembles myoclonus Loss of consciousness Slower

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

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

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

Case 1

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

Case 1 Confused Afebrile

First Non-Febrile Seizure

History Was this a true seizure or a non-

epileptic event?

History Circumstances

Normal activity vs. provoked Upon awakening

Duration Aura Abnormal motor movements Abnormal eye

movements/automatism

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

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

Always undress and examine the child

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

Neurofibromatosis (NF-1) Six or more, >5 mm in prepubertal Six or more, >15 mm in

postpubertal Crowe sign

freckled appearnace in axilla

Neurofibromatosis (NF-1) Present in 100% of patients present at birth Increase in size, number &

pigmentation Predilection for trunk & extremities Spare face

Lisch nodules Pigmented hamartomas of the iris NF-1 Prevalence increases with age

5% (<3 years) 42% (3-4 years) 100% (21 years)

Lisch nodules Asymptomatic Do not correlate with the extent &

severity Do not occur in normal individuals Best identified with slit lamp

Adenoma Sebaceum Erythematous papules over nose &

malar areas Develop between 4 and 6 years of

age coalesce & assume fleshy

appearance Tuberous sclerosis

Ash-leaf spots Hypo-pigmented Irregular borders May be present at birth Detectable by 2 years in 50% Wood’s ultraviolet lamp

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

Tuberous Sclerosis Infantile spasm Hypsarrhythmic EEG pattern

CT Scan Periventricular calcifications

MRI Multiple cortical tubers

Port-wine stain Macular cutaneous nevus Present at birth Always involves upper face & eye

lids unilateral Sturge-Weber Disease

Port-wine stain Tonic clonic seizure contralateral

to the side of facial nevus Refractory to anticonvulsant hemiparesis

CT Scan Normal at birth Gyriform contrast enhancement Hemispheric atrophy Parenchymal calcification

Railroad track

Physical Examination Café-au-lait spots (NF) Adenoma sebaceum (TS) Facial hemangioma (Sturge-

Weber) Petechiae (meningitis)

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

Diagnostic Evaluation Bedside glucose Serum Ca & Mg (< 3 months old) Urine drug screen CT head Outpatient EEG

Rolandic Epilepsy

Benign Partial Epilepsy with Centrotemporal Spikes (BPEC)

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

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

Infantile Spasm (West’s synd) Sudden jerks of group of muscles 4-12 months Characteristic EEG

(hypsarrhythmia) Poor prognosis ACTH/Steroid

Case 2

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 mother’s lap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted approx 5 minutes

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

Febrile Seizures

Febrile seizures Most common type of seizures in

the pediatric age usually benign Can cause considerable parental

anxiety

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

Febrile Seizures Age dependent Rare before 9 months & after 5

years Peak age 9-20 months Incidence 3 - 4% Family history Diagnosis of exclusion

Febrile Seizures Risk factors

Height of temperature Male sex Family history of febrile seizure

Febrile Seizures A family history of epilepsy has not

been shown to be a risk factor for first febrile seizures

Febrile Seizures Risk factors for recurrence

Young age at onset Febrile seizures in first degree

relative Lower degree of fever

Febrile Seizures Generalized tonic-clonic Duration few seconds to 10

minutes Excellent prognosis 20% are complex

Febrile Seizures Complex febrile seizure

> 15 minutes More than once in 24 hours Focal neurologic features

Febrile Seizures Risk of recurrence 34% Most recurrences within 6-12

months

Lumbar Puncture The decision to perform LP should

be based on the age of the child at presentation (AAP)

Lumbar Puncture < 12 months

Strongly recommend 12 - 18 months

Should consider > 18 months

If history & physical examination suggest intracranial infection

Febrile Seizures Signs of meningeal irritation

Unreliable under 18 months

Red flags Focal seizure Suspicious physical examination

findings (eg, rash, petechiae) cyanosis, hypotension, or grunting

Abnormal neurologic examination

Febrile Seizures Meningitis must be ruled out

Difficult if the patient is on antibiotics

Febrile Seizures Determine and treat the cause of

fever IV benzodiazepine Rectal diazepam No routine AED prophylaxis

Febrile Seizures Incidence of epilepsy

1% (No other risk factor) 9% (Other risk factors)

Epilepsy Family history of later epilepsy Preexisting neurologic abnormality Complex febrile seizure

> 15 minutes duration > 1 febrile seizure per 24 hour

Focal febrile seizure

Neonatal Seizures

Neonatal Seizures Seizures during first 28 days 0.5% of all live births Do not indicate epilepsy

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

Neonatal Seizures Neonates are at particular risk

Metabolic Toxic Structural Infectious

Neonatal Seizures Not generalized tonic-clonic

incomplete myelination Can be very subtle Minimal physical findings

Neonatal Seizures Subtle Tonic Clonic Myoclonic

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

Causes Perinatal asphyxia Intracranial hemorrhage Metabolic - hypoglycemia,

hypocalcemia Infections Drug withdrawl

History Family history

metabolic Maternal drug history Delivery

Mode & nature of delivery Fetal intrapartum status Resuscitative measures

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

Lab Serum chemistry Spinal fluid Metabolic work-up

serum ammonia amino-acids

Lab Head sonogram

IVH/periventricular CT head

Hemorrhage Calcifications Malformations

EEG

Management The method of treatment depends

on the cause Anticonvulsant

Phenobarbital

Status Epilepticus

Status Epilepticus Seizure >30 minutes Intermittent seizures longer than

30 minutes from which the patient does not regain consciousness

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%

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

Life-threatening causes Bacterial meningitis Hypoglycemia Increased intra-cranial pressure Hypoxemia Toxins

TCA, Cocaine, Theophylline, insulin

Management Rapid stabilization of cardio-

respiratory functions Termination of both clinical &

electrical seizures Diagnosis & treatment of life

threatening precipitant

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.”

Status Epilepticus Freeman JM: Status epilepticus: It’s

not what we’ve thought or taught. Pediatrics 1989;83:444-445

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

fosphenytoin)

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)

Diazepam IV 0.1 - 0.5 mg/kg Rectal 0.2 - 2 mg/kg

(maximum 10 mg)

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

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

Phenytoin 1950 - Massachusetts General Hospital

pH 12, limited solubility in waterPropylene glycol & ethanol

1956 - Parenteral formulation approved 1962 - pediatric dose recommendation 1986 - Revised Pediatric dose

(15-20 mg/kg, 1-3 mg/kg/min)

Phenytoin High pH

Burning & cutaneous reactions Purple glove syndrome

Phenytoin Propylene glycol

Seizures Arrhythmia Asystole Hepatic & renal damage Hemolysis Hyperosmolality Lactic acidosis

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

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

phenytoin

Sports Participation

Sports Participation Unnecessary restrictions Successful athelete with epilepsy

Gary Howatt (hockey player)

Sports Participation Which sport “Common sense” Significant metabolic imbalance

Scuba diving Potential for serious injury

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”

Permitted Sports Baseball basketball broad jumping hockey gymnastic Soccer wrestling

Reasonable precautions Bicycling Diving Football Skating Swimming

Prohibited Sports Boxing Bungee jumping Polo Scuba diving Skydiving Waterskiing

Driving & Regulatory Issues

Driver Licensing Each state has its own regulations “Seizure free period”

1 Year (NY)

Reporting responsibility Patient responsibility (most

states) Physician responsibility (Six

states) CA, DE, NE NJ, OR, PA

Employment

Employment Average intelligence Good health Unpredictable loss of

consciousness

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

Employment Interstate truck Forklift Working in heights

Pregnancy & Epilepsy

Pregnancy & Epilepsy 20,000 births women with epilepsy Lower seizure threshold

Offspring & AED

Offspring & AED Pheytoin

fetal hydantoin syndrome Valproate

neural tube defect Carbamazepine

spina bifida

Labor & Delivery

Labor & Delivery Bleeding tendency in neonate

induction of hepatic enzymes overcome by Vitamin K

Breast feeding & AED

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

Oral contraceptives & AED

Oral contraceptives & AED Increase the dose of Oral

contraceptives (AED induces hepatic

metabolism of hormones)

Don’t forget child abuse

Discrepancy between history & injury

“You are mandated by law to protect these children”

It’s 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

New AED’s

New AED’s Gabapentin (Neurontin) Lamotrigine (Lamictal) Vigabatrin (Sabril) Felbamate (Felbatol)

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

history