Childhood Seizures

CHILDHOOD SEIZURES
WHAT IS A SEIZURE
 It is a transient occurrence of signs and/or
symptoms resulting from abnormal excessive
or synchronous neuronal activity in the brain.
 Abnormal, involuntary, paroxysmal motor, sensory,
autonomic or psychomotor activity

TYPES OF SEIZURE
1. GENERALIZED [synchronous involvement of both
hemispheres]
a) Tonic-clonic
b) Absence seizure
c) Atonic
d) Myoclonic
2. FOCAL (PARTIAL)[originating from 1 hemisphere]
a) Simple partial (consciousness retained)
b) Complex partial (consciousness impaired)
3. UNKNOWN
4. EPILEPTIC SPASMS
AETIOLOGICAL CLASSIFICATION
A seizure may be
 Idiopathic
 Unprovoked seizure
 Cryptogenic (symptomatic)
 Metabolic derangement: hypoglycaemia,
hypocalcaemia etc
 Underlying brain disorder (structural/ functional)
 Infection of brain/ meninges
CAUSES
 Idiopathic/ UNPROVOKED
 Infection of brain and meninges
 Acute metabolic disturbance (Glucose/Ca, Mg, other
electrolytes)
 Inborn errors of metabolism/ storage disoders
 Structural abnormality of brain
 Neuro-degenerative disorders
 Vascular anomalies in brain
 Stroke
 SOL
 Drugs/poisons
 HIE sequelae
APPROACH TO SEIZURES
Active convulsion + No active convulsion

Treat attack Detailed history/exam/inv
Simultaneous history/exam Plan therapy
1st attack 1st attack 1st attack

Acute Repeat
Status
epilepticus
With fever symptomatic/
idiopathic attack
APPROACH TO SEIZURES
HISTORY regarding the attack  HISTORY others
 Age  Development
 Onset  Focal neurological
 Duration deficit
 Aura?  Evidence of neuro
 Description of attack infection?
 Post-ictal phase?  Metabolic
 Incontinence?
derangement?
 Loss of consciousness  Family history
 Recurrence?
Examination
(after seizure control)
 Febrile? Cause?
 Neck rigidity
 Raised ICT
 Detailed general & neurological examination to rule out
 Metabolic disorder
 Meningitis/ encephalitis
 Neuro-degenerative disorder
 HIE sequelae
 Syndromes
Investigation
 EEG
 Glucose/ Calcium/ Electrolytes
 CBC
 CSF study, cultures, metabolic study: as required
 Neuro-imaging
TREATMENT PLAN
 Treat acute episode : follow algorithm
 Treat febrile convulsion:
 Treat fever
 Assess
 Anti convulsant if required
 Prophylaxis if required
 Treat epilepsy
 Long term regime
 Treat underlying disease
Active Seizure Management
Maintain Airway, IV
Breathing Diazepam/Loraz
Circulation (ABC)
Positioning, Oxygen epam rpt after
10 mins
IV
IV line, CBG
Phenytoin IV
loading Valproate
dose
IV
IV
Levotera-
Phenobarb
cetam
Midazolam Ventilation &
Infusion Pentobarbital
EPILEPSY
 An unprovoked seizure is one that is not an acute
symptomatic seizure
 2 or more unprovoked seizures in a time frame of
longer than 24 hr: epilepsy
 Recurrent, episodic, paroxysmal, involuntary
clinical events (motor/ sensory/ psychomotor with
alteration of sensorium) associated with abnormal
electrical activity in the brain
Classification of Epilepsy
 Generalized Idiopathic/ Cryptogenic
 Focal /Partial (West Syn, Lennox Gastaut Syn,
Myoclonic)
 Syndromes:
 Rolandic
 Epilepsia partialis continua
 Progressive myoclonic
 Undetermined Syndromes
TONIC-CLONIC /GRAND MAL
 4 phases:
 Aura
 tonic
 clonic
 Post-ictal
 Incontinence in post-ictal phase
 EEG: generalized burst of spikes
ABSENCE SEIZURE/ PETIT MAL
 Age: 6-8 years

 NO aura or post-ictal phase
 Abrupt, brief loss of awareness/ consciousness
 Duration: < 30 secs
 EEG: 3/sec spike
FOCAL SEIZURE
 Initiated in one half of the brain
 Motor/ sensory/ autonomic/psychomotor/ mixed
symptoms
 Loss of consciousness in Complex partial
 Secondary generalization may happen
MYOCLONIC
Myoclonic seizures are rapid shock-like contractions, usually<50 msec in
duration
WEST SYNDROME
 Age: 3-8 mo
 It is a symptomatic epilepsy: secondary to brain disorder (HIE/ metabolic/structural…)
 Salaam attacks
 Developmental delay
 Hypsarrhythmia on EEG
LENNOX GASTAUT
 Age: childhood
 Symptomatic epilepsy
 Mixed seizures with myoclonus
 Developmental delay
 Specific EEG changes
Long term treatment of Epilepsy
Type of seizure drugs
Tonic-Clonic Carbamazepine, Phenobarb,
Na-Valproate
Absence Seizure Na-Valproate
Complex partial Carbamazepine
Myoclonic Leviteracetam, Na-Valproate,
Benzodiazepines
West Syndrome/ Infantile ACTH, prednisolone,
spasms vigabatrine
Newer broad spectrum Topiramate, Lamotrigine
FEBRILE SEIZURE
 Temperature of 38°C (100.4°F) or higher
 Not due to CNS infection or metabolic imbalance
 Age of 6 and 60 mo
 May be recurrent
 No history of prior afebrile seizures.
TYPES
SIMPLE FEBRILE SEIZURE:
 Generalized, usually tonic–clonic
 Associated with fever
 Lasting for a maximum of 15 min
 Not recurrent within a 24-hr period.
 Common in 6-60 months of age
 Very short post-ictal state , if any
 Return to their baseline normal behavior and consciousness within minutes of the
seizure
COMPLEX FEBRILE SEIZURE:

 Prolonged (>15 min)
 May be focal
 Recurs within 24 hr.
 Febrile status epilepticus :lasting > 30 min
 Predator of Epilelsy
Risk factors for recurrence
MAJOR
 Age <1 yr
 Duration of fever <24 hr
 Fever 38-39°C (100.4-102.2°F)
MINOR
 Family history of febrile seizures
 Family history of epilepsy
 Complex febrile seizure
 Male gender
 Lower serum sodium at time of presentation

RISK FOR SUBSEQUENT EPILEPSY
RISK FACTOR RISK FOR

EPILEPSY
Simple febrile seizure 1%
Recurrent febrile seizures 4%

Complex febrile seizures 6%
Fever <1 hr before febrile seizure 11%
Family history of epilepsy 18%
Focal febrile seizure 29%
Neurodevelopmental abnormalities 33%
DIAGNOSIS
 Exclude infection of the nervous system
 Exclude epilepsy
 Investigate after 2nd recurrence:
 EEG
 CSF study
 Neuro imaging
TREATMENT
 Treat fever: PCM
 Plenty of fluids
 Treat cause of fever
 Prophylaxis: Intermittent/ Continuous
 INTERMITTENT:
 During febrile episode
 Oral Clobazepam for 2-3 days
 CONTINUOUS (for recurrent/ atypical)

 Na-Valproate
 Phenobarbiturate

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CHILDHOOD SEIZURES

Active convulsion + No active convulsion

1st attack 1st attack 1st attack

 Age: 6-8 years

 Associated with fever

 Lasting for a maximum of 15 min

 Not recurrent within a 24-hr period.

 Common in 6-60 months of age

 Very short post-ictal state , if any

COMPLEX FEBRILE SEIZURE:

 Recurs within 24 hr.

 Febrile status epilepticus :lasting > 30 min

 Duration of fever <24 hr

 Fever 38-39°C (100.4-102.2°F)

 Family history of epilepsy

 Complex febrile seizure

 Lower serum sodium at time of presentation

RISK FACTOR RISK FOR

Simple febrile seizure 1%

Recurrent febrile seizures 4%

 CONTINUOUS (for recurrent/ atypical)

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