Julie Jaffray, MD Emily Pollakowski, MD

 Transient  Involuntary  Alteration in consciousness, behavior, motor activity, sensation or autonomic function  Due to abnormal electrical neuronal discharge in cerebral cortex  Signs and symptoms depend on location of discharge

 Febrile  Partial ◦ Simple partial ◦ Complex partial  Generalized ◦ Absence ◦ Myoclonic (muscle twitching) ◦ Clonic (rhythmic shaking) ◦ Tonic (rigid contracture) ◦ Atonic ◦ Tonic-clonic

 Seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of the central nervous system ◦ No previous neonatal seizure or previous unprovoked seizures  Vast majority are benign and rarely cause brain damage  Usually due to a rapid rise in temperature

 90% of febrile seizures occur between 6 months and 3 yrs of age  2-5% children will have a febrile seizure at some point  Simple febrile seizures (70-75%) ◦ Single, brief (<15min) generalized seizure during fever without intracranial infection or other causes and self resolves  Complex febrile seizures ◦ Lasts >15 min, focal, reoccurs within 24 hours

 Onset of seizure in a limited area, or one cerebral hemisphere  No impairment of consciousness  Highest incidence after 1 year of life  Risk of reoccurrence is higher than with generalized seizures  Can be sensory, motor or autonomic  Any structural lesion can causes SPS ◦ Vascular, meningitis/encephalitis, trauma, tumors, hypoxic insult, postsurgical changes, metabolic/electrolyte shifts, endocrine disorders, meds/toxins

 Starts focally within the brain then causes impairment of consciousness  Most commonly a manifestation of temporal lobe epilepsy  Typically last 30 sec-2 mins  Patient can describe an aura  Can be autonomic, simple motor, complex motor, negative (aphasic, atonic, hypomotor)

 Type of generalized seizure-not conscious  Brief, usually frequent throughout the day (in childhood absence)  Appear later in childhood  Staring spells, decline in school performance  Hyperventilation can provoke a seizure

 Occurs in several epilepsy syndromes  Initiated by 3 mechanisms ◦ Abnormal response of a hyperexcitable cortex ◦ Primary subcortical trigger ◦ Abnormal innervation from subcortical structures  May have a prodrome hours to days prior to seizure ◦ Mood changes, light headedness, anxiety, sleep disturbance, difficulty with concentration  Postictal state ◦ Variable period of consciousness, gradually wakens usually confused

 Any continuing type of seizure, but usually refers to a generalized convulsive state  Seizure lasting more than 30 mins ◦ Continuous or multiple seizures without gaining consciousness  Can lead to hypertension, tachycardia, cardiac arrhthmias and hyperglycemia  Mortality is 20%

 Neonatal seizure ◦ Can be tonic, clonic, myoclonic or subtle (blinking, chewing, bicycling, apnea-due to immature CNS) ◦ Usually a symptom of acute brain disorder  Hypoxic-ischemic encephalopathy  Intracranial hemorrhage/infarction  CNS infection  CNS malformation  Metabolic (hypoglycemia, hypocalcemia, toxins)  Inborn errors of metabolism  Infantile Spasms ◦ Head nodding and flexion or extension of trunk and extremities ◦ Often in clusters ◦ Onset 2 months, peak 4-6 months

 Intracranial infection (meningitis, encephalitis)  Intracranial tumor (benign or malignant)  Injury causing intracranial hemorrhage  Metabolic disturbances (hypoglycemia)

 Status Epileptus  Defined as > 30 minutes of continuous seizure activity or 2 or more sequential seizures in 30 minutes without full recovery of consciousness between seizures  Prepare for status with every seizure you witness -Medication dosing -Differential diagnosis

 Before anything else…A B C!  Airway  Breathing  Circulation  Stabilize patient  Establish access and obtain labs

 Airway -Appropriate positioning -Open airway, using head-tilt/chin-lift -If suspected head/Cspine trauma, jaw thrust -Rule out obstruction

 Breathing -Evaluate air exchange -Look and listen -Abnormal chest wall dynamics -If actively seizing: oxygen -If hypoventilating: ambu bag ventilation -Concern for aspiration

 Circulation -Rate Goal HR >100bpm (infant), >60bpm (child) -Rhythm -Assess pulses (central and peripheral) -Assess capillary refill -IV access, send off labs

 Diazepam 0.5mg/kg IV/PR (max 6-10mg)  Check FSBS (if possible)  D10 bolus, 5mls/kg -use 20ml syringe: 4ml D ml NS -repeat for full weight-based dose  Repeat diazepam if still seizing 5-10 minutes later  Think about next step

 Phenobarbital  Loading dose: 15-20mg/kg IV, then 5mg/kg q 30 minutes to max 30mg/kg  Maintenance: 5mg/kg/day IV, either BID or daily  Phenytoin/Fosphenytoin  Loading dose: 15-20mg/kg IV  Maintenance: 5mg/kg/day IV, divided BID, may increased to 8mg/kg/day

 Important to monitor closely during administration of above medications  Vitals (RR, HR, BP)  Level of consciousness

 Diazepam -Respiratory depression -Hypotension  Phenobarbital -Respiratory depression -Hypotension  Phenytoin -Hypotension -Arrythmias

 Stabilize the patient  Stop the seizure  Determine etiology (labs, imaging)  Eliminate precipitating factors  Reverse correctable causes  Observe  Determine long term plan and need for daily AED

 Too many drugs to remember!  Choice of AED depends on seizure type  Start with monotherapy, as 75% children with epilepsy will be, fully controlled  Polypharmacy is more expensive, decreases compliance, increases risk of toxicity