Pediatric Seizures Jeffrey Frank Child Neurology Oregon Neurology Associates

Disclosure I do not have a financial interest, arrangement or affiliation with any organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

Seizures Historically Ancient Babylonia – Miqtu – “the falling disease” – If a person loses consciousness and foams at the mouth, it is Miqtu – Miqtu – ‘to possess’ Ghosts and demons

Seizures Historically Hippocrates – Not a sacred disease – First to describe epilepsy as a brain disorder The Falling Sickness Shakespeare – Epilepsy – Othello 1603 – Epilepsia to seize to be taken hold of

Seizure Old French ‘seisir’ – to take possession by force Popular – sudden and severe event Medically – transient occurrence of signs and/or symptoms due to abnormal, excessive or synchronous neuronal activity in the brain – Epileptic Seizure

Epilepsy Historical - Two or more unprovoked seizures ILAE disorder of the brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiologic, cognitive, psychological, and social consequences of this condition. The definition of epilepsy requires the occurrence of at least one epileptic seizure

Epilepsy At least two unprovoked (or reflex) seizures occurring greater than 24 hours apart. One unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years. Diagnosis of an epilepsy syndrome – Epilepsy is considered to be resolved for individuals who had an age-dependent epilepsy syndrome but are now past the applicable age or those who have remained seizure-free for the last 10 years, with no seizure medicines for the last 5 years.

Seizure? Popular – sudden and severe event Medical – Epileptic seizure Synchronous neuronal activity – Nonepileptic seizure

Nonepileptic Seizures Psychogenic – Psychologically induced – Behavioral episode Nonpsychogenic – “Organic” but not of epileptic origin

Nonpsychogenic “Organic” Typically not responsive to anticonvulsants May still be stereotyped Any age

Nonepileptic Childhood Events

Breath Holding Spells Typically 6mos to 2yrs – Can extend to 5-6 years Provoked Gasp  Apnea  Pallor/cyanosis Altered sensorium, stupor or syncope Twitches or jerking movements Breathing returns after syncope Child typically recovers quickly

Benign Sleep Myoclonus Sudden, quick, jerk-like movement In sleep Not rhythmical Patient can be woken

Stereotypies Rigidly, repetitive and invariable Inappropriate in nature Head Banging Hand Flapping Body Rocking Toe Walking Echolalia

Benign Paroxysmal Vertigo Sudden onset dizziness or ataxia – Can be provoked by vestibular stimulation Typically lasts minutes – Can last up to 2 days May act very scared Often hold on to people/objects May be accompanied by headache

Non Epileptic All Ages

Migraine Variants Hemiplegia Loss of vision Aphasia / slurred speech Confusion Fluctuating consciousness Visual auras Vertigo

Syncope Often preceded by symptoms – Dizziness, darkening vision, weakness Loss of tone / Limp Pallor / Cyanosis Eyes closed May have convulsive mvmts Lucid on wakening

Tics Stereotyped Multiple versions – Motor or Vocal Suppressible Can be complex

“Normal” Behavior Daydreaming Sleep Confusional Arousal

Epileptic Seizures Stereotyped complex movements – May be focal or generalized – Though student may have multiple types – Evolution Paroxysmal – Clear beginning and end Involuntary / Uncontrollable Not distractible / interruptible Post-ictal phase

Generalized Seizure Types Generalized Tonic Clonic – ‘Grand Mal’ Tonic Seizure – Stiffening Myoclonic Seizure – Jerk-like movements Atonic – Sudden loss of postural tone Absence – ‘Petit mal’

Focal Seizure Types Focal Motor seizure – Sustained, rhythmical movements – May progress, migrate or generalize Clonic – Jerking movements Complex Partial – Alteration of awareness – Staring Autonomic

Psychogenic Nonepileptic “Pseudoseizure” Psychological / Psychiatric / Behavioral – Subconscious/unconscious symptoms Somatization Disorder Conversion – Conscious Factitious Malingering – Anxiety

Epileptic vs Psychogenic EpilepticPsychogenic Eyes openEyes closed Continuous w/evolutionStop and go Rhythmical movementsErratic / ‘thrashing’ Guttural sounds, aphasiaStuttering Fetal position, flexionOpisthotonic, arching EmesisCrying Tonic stiffeningThrusting Unresponsive*Responsive / aware* Amnesia*Recollection of event* *Patient may retain partial awareness/memory w/focal seizure

Acute Intervention Remain calm Check the time Thoughtfully observe while acting Check for medical ID / Seizure plan Place/roll patient to side – Prevent fall / gently help from chair/standing Do not restrict movements – Cushion if possible Do not put anything into mouth – Including medications

When to call EMS Any signs of cardiorespiratory compromise No known seizure disorder – No seizure action plan or – If seizure action plan indicates Seizure does not show signs of stopping after 5 minutes Second seizure begins before patient returns to neurological baseline Any signs of physical injury Unexpected focal neurological findings

After the Seizure Document details of seizure – Time of onset – Length – Description of movements, evolution – Triggers? – Post-ictal phase? – Awareness/responsiveness?

Medication Intervention Diastat – prepackaged rectal diazepam Dosing should be pre-dialed Rectal administration Typically administered if seizure > 5 min May cause side effects – Drowsiness – Confusion Minutes

Intranasal Midazolam May need to be drawn up ½ total dose in each nostril Typically for seizure > 5min May cause side effects – Drowsiness – Confusion Minutes

Oral Medications Rarely used Not to be given during seizure effective consciousness / swallowing ability May have role for cluster of events

Home? No EMS criteria Rapidly / progressively recovering No known triggers – Missed doses – Intercurrent illness / fever – Sleep deprived No history of clusters