Seizures and epilepsies in children Nebal Waill Pediatric neurology department Children Welfare Teaching Hospital

Terminology & Definition

Seizure : a sudden alteration in behavior, awareness, motor movement, body posture, autonomic function and/or sensory or psychic perception from both physiological (epileptic,chemical, anoxic, etc) and nonphysiological (psychological ) causes, which may be paroxysmal and stereotyped. Epilepsy :the tendency to have recurrent, unprovoked seizures caused by physiologically abnormal brain electrical activity produced by idiopathic or diverse brain pathologies. Convulsion: a sudden rhythmical motor behavior, body posture, or alteration in body tone from diverse physiological (epileptic, hypnic, chemical, anoxic, etc) and nonphysiological (psychological) causes, which may be paroxysmal and stereotyped.

tonic : characterized by increased tone or rigidity. Atonic seizure : are characterized by flaccidity or lack of movement during a convulsion Clonic seizure : consist of rhythmic muscle contraction and relaxation Myoclonic seizure : shock like contraction of a muscle.

Seizure categories Focal seizure ( previously known as partial or focal ) Generalized seizures ( convulsive or non convulsive ) Simple ( consciousness not impaired ) Complex ( with impairment of consciousness ) Focal seizures with secondary generalization Absence seizure Atypical absence seizures Myoclonic seizures Clonic seizures Tonic seizures Tonic – clonic seizures Atonic seizures Unclassified epileptic seizures

Focal seizures Simple 1.With motor symptoms 2.With somatosensory or special sensory symptoms 3.With autonomic symptoms 4.With psychic symptoms Complex Begin as simple focal and progressing to impairment of consciousness 1.With no other features 2.With features as in A With automatisms With impairment of consciousness at onset 1.With no other features 2.With features as in A With automatisms Focal seizures secondarily generalized

Focal arise in specific loci in the cortex which carry with them identifiable signatures either subjective or observational Generalized seizure involves large volumes of brain from the outset and are usually bilateral in their initial manifestations and associated with early impairment of consciousness Accordingly many different seizures in the immature would be left unclassified

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Evaluation of seizure 1.Determine whether it has a focal onset or is generalized 2.Describe the motor type 3.Document the duration of the seizure and state of consciousness ( retained or impaired ) 4.Determine whether an aura proceeded the convulsion & the most common aura experienced in children consists of epigastric discomfort or pain and a feeling of fear 5.Posture of patients 6.Presence and distribution of cyanosis 7.Vocalization 8.Loss of sphincter control ( particularly the urinary bladder ) 9.Post-ictal state ( sleep, headache, hemiparesis ) should be noted

Febrile convulsion FC : seizure in association with a febrile illness in the absence of a CNS infection or acute electrolyte imbalance in children older than 1 month of age without prior afebrile seizures Conditions : 1.Temperature : the key factor is the actual peak temperature, must be > 38.4 C˚ 2.Age : it’s age dependent, most common 6mo – 5 yr. 3.Classification Simple Generalized Isolate Brief : Duration < 15min Complex Focal Multiple ( > one in 24hr or febrile illness ) Prolonged : > 15min

Initial evaluation 1.LP: strongly considered < 12 mo 12-18mo = need careful assessment > 18 mo = not necessary in absence of suspicious findings on Hx & PE 4.Skull X-ray of no value 5.CT of limited benefit unless suspect trauma or ICP 6.MRI not indicated 7.EEG of limited value

Treatment Stopping FS By diazepam and if persist protocol of SE Education is key to empower the parents Keep child safe during seizure Preventing FS Intermittent medication Antipyretics : little evidence recurrence parent anxiety Diazepam : 0.33mg/kg/dose × 3 oral or rectal at the onset of febrile illness Barbiturates ( phenobarbital ) = ineffective Daily Phenobarbital effective but S.E Valproate effective Others not effective or toxic Preventing epilepsy No evidence

Very general rule of thumb to treat epilepsy 1.Generalized epilepsies and syndromes : Na Valproate 2.Focal seizures +/- generalization : carbamazepine lamotrigine

Status epilepticus Functionally a seizure lasting more than 30 (5, 10) minutes or recurrent seizures lasting more than 30 (5,10) minutes from which the patient does not regain consciousness

Precipitating Events AED alteration : noncompliance Withdrawal Interaction toxicity Infections CNS Systemic Toxins Alcohol Drugs Poisons Convulsive agents Structural Trauma Ischemic stroke Hemorrhagic stroke Acute hydrocephalus Hormonal change Diagnostic procedures and medications Emotional stress Electrolytes imbalance Sleep deprivation Primary apnea Cardiac arrhythmia Progressive-degenerative disease fever

Medical complications of SE Tachycardia Bradycardia Cardiac arrhythmia Cardiac arrest Conduction distrubance Congsetive heart failure Hypertension Hypotension Altered respiratory pattern Pulmonary edema Pneumonia Oliguria Uremia RTA Lower nephron nephrosis Rhabdomyolysis Myoglobinuria Apnea Anoxia Hypoxia CO2 narcosis Intravascular coagulation Metabolic and respiratory acidosis Cerebral edema Excessive perspiration Dehydration Endocrine failure Altered pituitary function Elevated prolactin Elevated vasopressin Hyeperglycemia Hypoglycemia Increased plasma cortisol Autonomic dysfunction Fever

Treatment of status epilepticus 1.Transferred to ICU 2.ABC 3.Remove by gentle suction excessive oral secretion 4.Properly fiting face mask attached to O2 5.Ambubag 6.N/G 7.i.v catherter

8.Rx hypoglycemia 9.Blood sample 10.± CSF 11.Neuroimaging 12.Concurrently perform physical and neurological examination

Benzodiazepine : Diazepam Lorazepam midazolam phenobarbitone Benzodiazepine infusion: midazolam, diazepam, propofol Phenytoin / phosphenytoin Barbiturates coma : thiopental Paraldehyde GA: halothane, isoflurane

Physical and neurological examination 1.Papilledema 2.Ant. Fontanel 3.Retinal hemorrhage 4.Kussmaul breathing + dehydration 5.Peculiar body odor 6.Abnormal hair pigmentation 7.Pupillary dilatation or constriction 8.After control seizure take detailed history

Doses of drug used in SE Diazepam mg/kg at rate not more than 2mg/min Diazepam repeated for max. of 3 doses.

Phenytoin If the convulsive activity cease after diazepam or lorazepam therapy or if seizures persist Phenytoin : 15-30mg/kg i.v infusion rate 1mg/kg/min If seizure don’t recur maintenance [3-9mg/kg/day ÷ 2 began 12-24hr

phenobarbital Followed by or in some center initiated with Loading : 15-20mg over 10-30min. With control of seizure, maintenance 3-5mg/kg/day ÷ 2

Mortality rate of status epilepticus = 5% Greatest number of death occur in symptomatic type Long-term complications : 1.Hemiplagia 2.Extrapyramidal syndrome 3.Mental retardation 4.Epilepsy