The Seizing Child (2)

8/6/2019 The Seizing Child (2)

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Pediatric Seizures

Muhammad Waseem, MDMuhammad Waseem, MD

Emergency MedicineEmergency MedicineLincoln HospitalLincoln Hospital



Few things are more frightening to

parents than to witness their childhaving 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 activityin the brain

Paroxysmal alteration in neurologicfunction (i.e, behavioral, motor, or

autonomic function, or all three - volpe1989.



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 & abnormaltissue



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 schoolage



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



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 crawlinginside me

No post-ictal phenomenon



Complex Partial Seizures (CPS) Impairment of consciousness

Aura

Brief blank stare or sudden cessation orpause 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 alternatingwith 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 bynoise from his bed room

Noted bed sheets awry & breathingdeeply

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)



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%

Woods 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 withCentrotemporal 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 (Wests 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. Onthe same afternoon while sitting on hismothers lap he began to stare and had

a generalized tonic-clonic seizure. Theentire 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 withfever, 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 < 12 months

Strongly recommend

12 - 18 months Should consider

> 18 months

If history & physical examination suggest intracranial infection



Red flags Focal seizure

Suspicious physical examination

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

Abnormal neurologic examination



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



Lab

Head sonogram

IVH/periventricular

CT head Hemorrhage

Calcifications

Malformations EEG



Management

The method of treatment depends onthe cause

Anticonvulsant Phenobarbital



Status Epilepticus



Status Epilepticus Seizure >30 minutes

Intermittent seizures longer than 30

minutes from which the patient doesnot regain consciousness



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-respiratoryfunctions

Termination of both clinical & electricalseizures

Diagnosis & treatment of life

threatening precipitant



Status Epilepticus The child is often given too much IVbenzodiazepine.Blood gases are

measured and perhaps the values arefound to be slightly decreased. Thechild is then paralyzed, intubated, andsent to the intensive care unit torecover from the iatrogenic morbidity.



Status Epilepticus Freeman JM: Status epilepticus: Its not

what weve 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 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)



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 prematureneonate is about seven times greaterthan WHO standard



Fosphenytoin 1996 Pro-drug of phenytoin

pH 8

Far more soluble in water

No organic solvent

Both IV & IM

Rapid & complete conversion tophenytoin



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 in jury



AMA Committee for Sports Patients with epilepsy will not be

affected by indulging in any sport,

including foot ball, provided the normalsafegaurds for sports participation arefollowed, including adequate headprotection



Reasonable precautions Bicycling

Diving

Foot ball

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 mayexpose them or their coworkers to riskor in jury



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 Oralcontraceptives

(AED induces hepatic metabolism of hormones)



Dont forget child abuse

Discrepancy between history &in jury



You are mandated by law toprotect these children



Its not optional

New York State Law (Social ServicesLaw Section 413) requires that any

health professional who suspects that achild is being endangered or maltreatedmust report his/her suspicion to NY City, to the local child protectionservices



New AEDs



New AEDs

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

The Seizing Child (2)

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