October 21, 2011 GOOD MORNING! WELCOME APPLICANTS!

What to do? FIRST NONFEBRILE SEIZURE

 25,000 to 40,000 per year  Cannot be explained by an immediate, obvious provoking cause such as head trauma or intracranial infection NONFEBRILE SEIZURE

HISTORY

 Age  Family History  Developmental Status  Behavior  Health at seizure onset – febrile, ill, exposed to illness, sleep deprived  Precipitating event other than illness – trauma, toxins ASSOCIATED FACTORS

 Aura  Behavior  Preictal symptoms  Vocal  Motor  Head or eye turning, eye deviation, posturing, jerking, stiffening, automatisms  Respiration  Autonomic  Pupillary dilation, drooling, incontinence, vomiting  Loss of consciousness SYMPTOMS DURING SEIZURE

 Amnesia  Confusion  Lethargy  Sleepiness  Headaches  Muscle aches  Transient focal weakness (Todd’s paresis)  Nausea or vomiting SYMPTOMS FOLLOWING SEIZURE

 Breath-holding spells  Syncope  GERD  pseudoseizures IS IT REALLY A SEIZURE?

PHYSICAL

PHYSICAL EXAM  State of consciousness, language, social interaction  Global development  Dysmorphic features, neurocutaneous skin findings, organomegaly, limb asymmetry  Head circumference  Neuro exam  Cranial nerves  Motor strength and tone  Reflexes  Gait  Cerebellar and sensation tests

EVALUATION

LABORATORY STUDIES

 Recommendations  Should be ordered based on individual clinical circumstances that include suggestive historic or clinical findings such as vomiting, diarrhea, dehydration, or failure to return to baseline status  Toxicology screening should be considered across the entire pediatric age range if there is any question of drug exposure or substance abuse CBC, BMP, CALCIUM, TOX SCREEN?

 Children under 6 months of age  Some studies show a 70% incidence of hyponatremia associated with seizures in this age group EXCEPTION TO THE RULE

LUMBAR PUNCTURE

 Recommendation  In the child with a first nonfebrile seizure, LP is of limited value and should be used primarily when there is concern about possible meningitis or encephalitis LUMBAR PUNCTURE

EEG

 Recommendation  The EEG is recommended as part of the neurodiagnostic workup of the child with an apparent first unprovoked seizure EEG

 Helps to determine seizure type, epilepsy syndrome, and risk for recurrence  Optimal timing is not clear  An EEG done in the first 24 hours will most likely show abnormalities, but can be due to postictal slowing  There is no evidence that the EEG must be done before discharge from the ED  Can be arranged on an outpatient basis EEG

NEUROIMAGING

 Recommendations  If a study is obtained, MRI is the preferred modality  Emergent neuroimaging should be performed in a child of any age who exhibits a postictal focal deficit or who has not returned to baseline within several hours after the seizure  Nonurgent neuroimaging with MRI should be seriously considered in any child with a significant cognitive or motor impairment of unknown etiology, unexplained abnormalities on neuro exam, a focal seizure, an EEG that does not represent a benign partial epilepsy of childhood or primary generalized epilepsy, or in children under 1 year of age NEUROIMAGING

TREATMENT

 Discuss all strategies with patient/parents  Antiepileptic drugs  Special diets (ketogenic diet)  Surgery  Vagus nerve stimulation  Most neurologists do not recommend AEDs after a first seizure because only 30% have a second seizure  After 2 seizures, the risk of having a third one increases to about 75% without treatment  AED is usually started after 2 seizures  1/3 of patients are refractory to medication TO TREAT OR NOT TO TREAT?

SEIZURE PRECAUTIONS

PRECAUTIONS  Patient/parents should be informed about possible precipitating factors:  Sleep deprivation  Hyperventilation  Alcohol abuse  Recreational drugs  Photic light stimulation

 Yes! They can participate in sports  Basic safety precautions  No swimming or bathing alone CAN THEY PLAY SPORTS?

 Yes! They can drive  Each state has different laws  Most suggest being seizure free for 6-months CAN THEY DRIVE?

Noon Conferenc e OUTER EAR DISEASE, DR. SIMON