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M a x A n g e l o G . T e r r e n a l
Seizures andStatus Epilepticus
in Children
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What is a SEIZURE?
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paroxysmal involuntary motor activity
and/or
changes in behavior
caused by synchronous firing of a group of neurons in the brain
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glutamate vs
GABA
excitatory
inhibitory
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electroencephalogram
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Children less than 5 years old
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Children less than 5 years old
excitatory > inhibitory
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excitatory > inhibitory
Children less than 5 years oldPeriod of Vulnerability
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cognitive impairment and
behavioral abnormalities
CNS disease or anticonvulsants?
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A single prolonged
seizure has been
shown to damage the brain
30
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temporal lobes
andhippocampus
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seizure disorders
are the most common neurologic
disorders of childhood
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4 to 10% suffer at least one seizure in
the first 16 years
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30%who have a first afebrile
seizure develop epilepsy
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3% cumulative lifetime incidence
of epilepsy
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FEBRILE SEIZURES
30%recur after first episode
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FEBRILE SEIZURES
50%recur after 2 or more
of infants <1 y/o at onset
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FEBRILE SEIZURES
2-7%proceed to epilepsy
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CLINICAL
PRESENTATION
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syncopePreceded by • dizziness• weakness• tunnel vision• pallor• diaphoresis
Associated with • brief loss of
consciousness
• quick recovery with no postictal state
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seizurescyanosis
tongue bitingrhythmic motor activity
incontinenceslow recovery and postictal
state
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convulsive generalizedboth hemispheres
motor activity on both sides
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nonconvulsivegeneralized
both hemispheresno motor activity
recognizable by EEG
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other generalized
absenceatonicmyoclonic
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other generalized
absenceatonicmyoclonic
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other generalized
absenceatonicmyoclonic
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other generalized
absenceatonicmyoclonic
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simple febrile seizures
or
complex febrile seizures
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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simple febrile seizuresgeneralized tonic-clonic
<15 minutes
> fever of 380C
6 months to 5 years of age
once in a 24-hour period
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complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
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complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
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complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
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complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
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complex febrile seizuresfocal
>15 minutes
< 6 months to > 5 years of age
recur within a 24-hour period
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febrile seizuresanticonvulsant therapy is not
recommended for simple febrile
seizures
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STATUS EPILEPTICUS
prolonged or recurrent
>5 minutes without regaining
consciousness
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REFRACTORY STATUS EPILEPTICUS
uncontrolled with 2 or more standard
doses of treatment
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most seizures stop within 5
minutes and do not require medical
treatment
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Status Epilepticusseizure > 5 minutes
or
multiple seizures over a
period of > 5 minutes
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PREHOSPITAL
benzodiazepine
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Oxygen support
IV access
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Oxygen support
IV access
• Rapid bedside electrolyte level
• Complete blood count
• Full chemistry panel
• Hepatic and renal studies
• Anticonvulsant levels
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intubate = clinicalapnea and persistent hypoxia
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blood gas concentration
paralytic
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blood gas concentration
paralytic
metabolic and respiratory Acidosis
obscure assessment
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continuous EEG monitoring
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benzodiazepinesFIRST LINE
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FIRST LINE
benzodiazepinesbind to GABA receptors
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benzodiazepinesFIRST LINE
Diazepam
Lorazepam
Midazolam
Lorazepam
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benzodiazepinesFIRST LINE
Diazepam
Lorazepam
Midazolam
Lorazepamfewer side effectslonger duration
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Initial benzodiazepine treatment
should be limited to 2 doses
FIRST LINE
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SECOND LINEfosphenytoin
or phenobarbital
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SECOND LINEfosphenytoin
phenytoinstabilizing sodium channels
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SECOND LINEphenobarbital
bind to GABA receptors
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SECOND LINEfosphenytoin >
phenytoin
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SECOND LINEfosphenytoin >
phenytoinprecipitate in an IV linehypotension
cardiac arrhythmias
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SECOND LINEfosphenytoin >
phenytoinprecipitate in an IV linehypotension
cardiac arrhythmiasmust be given slowly
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SECOND LINEfosphenytoin >
phenobarb
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SECOND LINEfosphenytoin <
phenobarballergies to phenytoin
with a febrile illness
<2 years of age
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THIRD LINEvalproic acidlevetiracetam
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low electrolyte levelshypoglycemiahyponatremiahypocalcemia
hypomagnesemia
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hypoglycemiaGlucose < 50 mg/dl
2 ml/kg 25% dextrose in water
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hyponatremiaSodium < 135 mEq/L
Seizures at < 120 mEq/dl3% NaCl for active seizures
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hypocalcemia10% calcium gluconate
0.3 mL/kg
slowly over 5 to 10 minutes
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hypomagnesemiaMg < 1.5 mEq/L
50 mg/kg IV infused over 20 minutes
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Philippine CPG
first febrile seizure
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lumbar puncture should be
performed in all children
below 18 months with a first
simple febrile seizure
Philippine CPG
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children 18 months and older,
lumbar puncture should be
performed in the presence of clinical signs
Philippine CPG
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meningeal signsand
sensorial changes
Philippine CPG
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neuroimaging studies should not be routinely
performed
Philippine CPG
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Antipyretic drugs are used to
lower fever and should not be relied upon to prevent the
recurrence of febrile seizures
Philippine CPG
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For a first simple febrile seizure
the use of intermittent or continuous
(phenobarbital or diazepam)
is not recommended for
the prevention of recurrent febrile seizures.
Philippine CPG
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Electroencephalogram
should not be routinely
requested
Philippine CPG