The Child with Fits Lydia Burland

Learning Outcomes By the end of the session you should;  Know of the common causes of seizure, including febrile fits and childhood epilepsy syndromes  Be able to explain to parents pathophysiology, as well as further investigation and management  Be able to manage seizures acutely  Be able to answer questions on the topic

Childhood Seizures  600,000 people with epilepsy in the UK  Inappropriate sensory or motor activity due to abnormal signalling in the brain  Causes include; Primary epilepsyCranial malformation InfectionTrauma/injury FeverSpace occupying lesions SyncopeElectrolyte abnormality

Childhood Seizures  Focal seizures: – seizure activity in a localised part of the brain with no loss of consciousness (LOC) – most commonly arising from the temporal and frontal lobes  Generalised seizures: – seizure activity throughout both hemispheres, associated with LOC – types of generalised seizure include tonic-clonic, tonic, atonic, myoclonic and absence

Acute Management With IV AccessWithout IV Access 0 minsABCDE assessment, oxygen, IV access, check BG 5 minsLorazepam 0.1mg/kgMidazolam 0.5mg/kg (buccal) 15 minsLorazepam 0.1mg/kgMidazolam 0.5mg/kg (buccal) 25 minsPhenytoin 20mg/kg over 20 mins OR (if on regular phenytoin) Phenobarbital 20mg/kg over 5 mins Call for senior help Secure intraosseous access Consider paraldehyde 0.8ml/kg 45 minsPICU input Consider RSI with thiopental 4mg/kg PICU input

Long-term Management  If a patient presents with a seizure you should; – Take a full history – Examine fully, including CNS/PNS – Identify and treat likely cause – If suspicious for epilepsy refer to neurology clinic – Arrange an outpatient EEG +/- imaging  Once a diagnosis is made a neurologist will decide if treatment is needed

Advice for Patients and Parents Once a diagnosis of epilepsy has been made you should advise;  Patients should not lock the bathroom door when taking a bath  Patients should wear a helmet when riding a bike  Inform lifeguards of their diagnosis if going swimming  That epileptic patients cannot drive unless fit-free for a year

Non-Epileptic Attacks

Febrile Convulsions  Convulsion associated with high fever, in the absence of another cause  Affect 2-4% of children  Most common between 6 months and 6 years  Positive family history in around 25%  Aetiology is unclear, common precipitants include viral illness, otitis media and tonsilitis

Febrile Convulsions  Simple convulsions are; – tonic-clonic – last less than minutes – do not recur within the same illness  Complex convulsions may start focally, last longer than 15 minutes, or recur  Febrile status occurs in 5%

Febrile Convulsions  May not need further investigation if clear source  Treat with antipyretics if the child is distressed, +/- antibiotics for the causative infection  If any doubt about the cause of the seizure a full septic screen should be performed  Treat with broad spectrum IV abx if the origin of infection is not known  Reassure parents and teach them how to manage further seizures

Reflexic Anoxic Attacks  Brief episodes of asystole triggered by pain, fear or anxiety  The child becomes suddenly pale, limp and loses consciousness, followed by a tonic-clonic phase  Episodes usually resolve in 30-60seconds, after which children may feel tired  These are non-epileptic events  Can occur at any age, but most common between 6 months and 2 years or age

Reflexic Anoxic Attacks  Diagnosis is usually based on the history, with a normal ECG and EEG  Once a diagnosis has been made parents should be reassured  If further attacks occur the child should be placed in the recovery position  The majority of children grow out of attacks, though they may recur later in life

Childhood Epilepsy Syndromes

Case 1  Toby is brought to see his GP as school are complaining that he is ‘day-dreaming’ in class  It happens around times a day  He is otherwise developmentally normal  Mum says his dad use to ‘day-dream’ when he was younger  What is the most likely diagnosis?

Case 1: Childhood Absence Epilepsy  Onset between 3-12 years of age  Frequent absence episodes lasting 5-20 seconds  May have associated ‘automatisms’ such as eyelid flickering and lip-smacking  Child is otherwise normal and there is often a positive family history  Seizures remit in adolescence without treatment  The use of carbemazepine can increase seizure frequency

Case 2  A 15 year old girl is brought into A+E after she experiences a tonic-clonic seizure  She was at a family party until late last night, where she did not drink any alcohol or use any illicit drugs  She had a similar episode after a sleep-over last month which has not been investigated  Her mum says she is clumsy and often drops things when getting breakfast ready in the morning  What is the most likely diagnosis?

Case 2: Juvenile Myoclonic Epilepsy  Onset between 8-26 years, more common in girls  Characterised by; – Tonic-clonic seizures provoked by sleep deprivation – Absence seizures – Early morning myoclonic jerks of the upper limbs  May be triggered by flashing lights (40%), sleep deprivation and alcohol  The majority are well controlled with anti-epileptics, which may need to be taken lifelong

Case 3  A 9 year old presents with frequent episodes of salivation and aphasia during the night, he is awake throughout and appears upset  His mum says she has noticed some facial twitching during these episodes  He is otherwise fit and well, and has had no day time symptoms  What is the most likely diagnosis?  What would you tell his parents regarding prognosis?

Case 3: Benign Rolandic Epilepsy  Onset between 3-12 years, peak at 9 years  Nocturnal, benign seizures  Unilateral paraesthesia of the face, with ipsilateral facial motor seizure  No LOC but unable to speak, and often salivation  Last around 1-2 minutes  Day time seizures are rare  Seizures resolve during puberty without treatment

Case 4  A 3 year old presents with episodes where he repeatedly flexes his trunk forcefully and throws his arms up  His mum has also noted that he; – Is less steady on his feet – Can no longer draw or use a fork and spoon  An EEG shows asynchronous spikes on a chaotic background  What type of seizure is described ?  What is the most likely diagnosis?

Case 4: West Syndrome  Triad of; – Infantile spasms – Motor regression – Typical EEG pattern  Poor prognosis with 5% mortality  Survivors have severe developmental delay and persistent seizures  Vigabatrin, steroids and ACTH can be used to control infantile spasms

In Summary  Seizures in childhood are caused by many different mechanisms  The diagnosis often unclear following the 1 st episode, a good history is the basis of diagnosis  Investigations include EEG and brain imaging  Prognosis is dependent upon the cause – some seizures are benign, whilst others need life-long treatment  Is it important to communicate clearly with parents and advise appropriately

EMQ Questions

Questions a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmf. Juvenile myoclonic 1.An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly goes pale and drops to the floor where she twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

Questions a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

Questions a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 3.A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

Questions a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 1.An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

Questions a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 2.A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

Questions a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 3.A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

EMQ Answers

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmf. Juvenile myoclonic 1.An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmf. Juvenile myoclonic 1.An 18 month old is playing with her brother when she bumps her head on a door frame. She suddenly drops to the floor and twitches her arms and legs for 1 minute. When she comes round she is drowsy but otherwise well.

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 2. A 9 month old boy has had clusters of episodes where he flexes his trunk and spreads his arms out. These happen in the morning, and is otherwise developmentally normal.

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 3.A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

Answers a.Febrile fitb. Reflexic anoxic attack c.Absence seizured. Benign Rolandic e. Infantile spasmsf. Juvenile myoclonic 3.A 13 year old girl has had isolated muscle spasms for the last few weeks, she initially ignored them but is now annoyed as she keeps spilling drinks. She is otherwise well.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 1.An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 1.An 8 year old is in class when her teacher notices she is not responding to voice, and is chewing her lips repetitively.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 2.A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 2.A 7 year old boy presents with several episodes where he smells ‘something funny’ and feels nauseated, before several minutes of lip smacking.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 3.A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

Answers a.Tonic-clonicb. Atonic c.Absence d. Myoclonic e. Focal (frontal lobe)f. Focal (temporal lobe) 3.A 5 year old boy suffers from frequent ‘drop’ attacks that come on without warning. He suddenly drops to floor, then recovers spontaneously without any memory of the event.

Any questions? Lydia Burland