seizure in children
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SEIZURE IN CHILDREN
BY
Shikha.S.A
2nd
Year MSc (N)
Definition
A seizure is a sudden disruption of the brain's normal electrical activity accompanied by altered consciousness and/or other neurological and behavioural manifestations.
Epilepsy is a condition characterized by recurrent seizures that may include repetitive muscle jerking called convulsions.
ETIOLOGY
Low oxygen during birth
Head injuries that occur during birth or from accidents during youth or adulthood
Brain tumours
Genetic conditions that result in brain injury, such as tuberous sclerosis
Infections such as meningitis or encephalitis
Stroke or any other type of damage to the brain
Abnormal levels of substances such as sodium or blood sugar
RISK FACTORS
Age - The onset of epilepsy is most common during early childhood and after age 60, but
the condition can occur at any age.
Family history
Head injuries - Head injuries are responsible for some cases of epilepsy.
Stroke and other vascular diseases - Stroke and other blood vessel (vascular) diseases
can lead to brain damage that may trigger epilepsy.
Brain infections - Infections such as meningitis, which causes inflammation in the brain or
spinal cord, can increase the risk.
Seizures in childhood - High fevers in childhood can sometimes be associated with
seizures.
CLASSIFICATION OF SEIZURE
Seizure
Generalized
Partial
Tonic-Clonic
Absence
Myoclonic
Clonic
Tonic
Atonic
Simple partial
Complex partial
Generalized seizure
Generalized Seizures(Produced by the entire brain)
Symptoms
1. "Grand Mal" or Generalized tonic-clonic Unconsciousness, convulsions, muscle rigidity
2. Absence Brief loss of consciousness
3. Myoclonic Sporadic (isolated), jerking movements
4. Clonic Repetitive, jerking movements
5. Tonic Muscle stiffness, rigidity
6. Atonic Loss of muscle tone
Partial seizure
Partial Seizures
(Produced by a small area of the brain)
Symptoms
1. Simple(awareness is retained)
a. Simple Motor
b. Simple Sensory
c. Simple Psychological
a. Jerking, muscle rigidity, spasms, head-turning
b. Unusual sensations affecting either the vision,
hearing, smell taste, or touch
c. Memory or emotional disturbances
2. Complex(Impairment of awareness)
Automatisms such as lip smacking, chewing,
fidgeting, walking and other repetitive, involuntary
but coordinated movements
3. Partial seizure with secondary generalization
Symptoms that are initially associated with a
preservation of consciousness that then evolves into
a loss of consciousness and convulsions.
STATUS EPILEPTICUS (SE)
Is a life-threatening neurologic disorder defined as 30 minutes or more of a continuous seizure, or two or more discrete seizures without complete recovery of consciousness between seizures.
Two common forms of SE are generalized convulsive SE, involving prolonged seizures, and nonconvulsive SE, involving changes in behaviour, memory, affect, or level of consciousness.
Cont.…….
Treatment must begin immediately after diagnosis, because SE of long duration is associated with an increase in neurologic morbidity and seizures may become less responsive to medication with time.
Begin treatment with supportive care; ensuring sufficient oxygenation is essential. If seizures do not terminate on their own, administer antiepileptic medication
Causes of SE
Fever
Pre-existing epilepsy
Genetic predisposition
Cerebral palsy
Stroke or brain insults, such as prior or acute head trauma, CNS infection, and cerebrovascular disease including arterial ischemic stroke or intracranial haemorrhage
Progressive neurologic disorders such as brain tumour or neurodegenerative disease
Hypoxic-ischemic encephalopathy
Metabolic and electrolyte disturbances (e.g., hypoglycaemia, hyponatremia, hypernatremia, hypercalcemia)
Drug intoxication (alcohol, cocaine, theophylline, tricyclic antidepressants, amphetamines, insulin)
Acute withdrawal of AEDs
Progressive neurologic disorders such as brain tumours or neurodegenerative diseases
IMMEDIATE CARE
Verify diagnosis
Obtain brief history focusing on known convulsive disorders, medication usage, and any recent medication changes, drug allergies, alcohol or substance misuse, recent acute illness, chronic disease, or previous brain injury.
Initiate supportive care
Assess and secure airway and oxygenation; insert nasal airway or intubate if necessary. Administer 100% oxygen
Monitor pulse, blood pressure, respiration, and temperature
Secure intravenous access in large vein
CONT…..
Send blood for complete blood count, serum electrolytes, calcium, magnesium, blood urea nitrogen, liver function tests, glucose, and antiepileptic drug levels, clotting studies, and toxic drug screen
Check arterial blood gases
Begin isotonic saline at a low infusion rate
Give 50 mL of 50% glucose intravenously if hypoglycemia is suspected, or prophylactically if glucose levels cannot be determined
SIGNS AND SYMPTOMS
Generalized absence seizures
Staring
The child suddenly stops what she is doing
A few seconds of unresponsiveness (usually less than 10 seconds, but it can be up to 20 seconds) that can be confused with daydreaming
No response when you touch your child
The child is alert immediately after the seizure
The child may have many seizures per day
Repetitive blinking
Eyes rolling up
Head bobbing
Generalized myoclonic seizures
One or many brief jerks, which may involve the whole body or a single arm or leg
In juvenile myoclonic epilepsy, these jerks often occur upon waking
The child remains conscious
Generalized atonic seizures
Sudden loss of muscle tone
The child goes limp and falls straight to the ground
The child remains conscious or has a brief loss of consciousness
Eyelids droop, head nods
Jerking
The seizure usually lasts less than 15 seconds, although some may last several minutes
The child quickly becomes conscious and alert again after the seizure
Generalized tonic-clonic seizures
The child cries out or groans loudly
The child loses consciousness and falls down
Heart rate and blood pressure rise
Sweating
Tremor
In the tonic phase, the child is rigid, her teeth clench, her lips may turn blue because blood is being sent to protect her internal organs, and saliva or foam may drip from her mouth; she may appear to stop breathing because her muscles, including her breathing muscles, are stiff
Cont.........
In the clonic phase, the child resumes shallow breathing; her arms and legs jerk quickly and rhythmically; her pupils contract and dilate
At the end of the clonic phase, the child relaxes and may lose control of her bowel or bladder
Following the seizure, the child regains consciousness slowly and may appear drowsy, confused, anxious, or depressed.
Simple partial seizures
Motor seizures
Brief muscle contractions (twitching, jerking, or stiffening), often beginning in the face, finger, or toe on one side of the body.
Twitching or jerking spreads to other parts of the body on the same side near the initial site.
Other motor seizures may involve movement of the eye and head.
The seizure begins the same way each time.
The child remains conscious.
Cont……..
Sensory seizures
Seeing something that is not there, such as shapes or flashing lights, or seeing something as larger or smaller than usual
Hearing or smelling something that is not there
Feeling of pins and needles or numbness in part of the body
The child remains conscious
Cont…….. Autonomic seizures
Changes in heart rate
Changes in breathing
Sweating
Goose bumps
Flushing or pallor
The child remains conscious
Strange or unpleasant sensation in the stomach, chest, or head
Changes in heart rate
Changes in breathing
Sweating
Goose bumps
Flushing or pallor
The child remains conscious
Complex partial seizures
Warning sign such as a feeling of fear or nausea
Loss of awareness
Confusion after the seizure
Loss of memory about events just before or after the seizure
Loss of awareness
Blank stare
Walking or running
Automatisms such as mouth movements, picking at air or clothing, repeating words or phrases
Confusion after the seizure
Loss of memory about events just before or after the seizure
DIAGNOSIS
Blood tests (such as blood sugar, complete blood count, electrolytes and liver and kidney function tests)
Electroencephalography (EEG), a test that records electrical activity in the child’s brain
Brain imaging tests including CT, MRI and PET scans to look for any scar tissue, tumors or brain malformations that may be causing seizures
Spinal tap (lumbar puncture) to see if there is an infection or other problem
PET /SPECT-Radioisotopes, radioactive materials injected into the vein and traced with either PET or SPECT with to detect areas of brain epileptic foci.
TREATMENT
Principles of Treatment
Treatment should be started with a single conventional AED (monotherapy).
The dose should be slowly built up until seizure control is achieved or side effects occur.
If the initial treatment is ineffective or poorly tolerated then monotherapyusing another AED can be tried
The dose of the second drug is slowly increased until adequate or maximum tolerated dose is reached.
The first drug is then tapered off slowly.
Combination therapy (polytherapy or adjunctive or “add-on “therapy) can be considered when two attempts at monotherapy with AEDs have not resulted in seizure freedom.
CONT……..
Phenytoin (PHT), phenobarbitone (PB), carbamazepine (CBZ), oxcarbazepine (OXC) and valproate (VPA) are usually called “conventional” or “first-line drugs”.
The other AEDs are called “new "or “second-line drugs”.
It is preferable to use a conventional AED as the initial drug since those are less expensive and the side effects with long-term use are well-known.
SURGERY
Epilepsy surgery may be resective or nonresective.
Resective surgery includes lesionectomy (resection of the lesion and the surrounding epileptogenic area), amygdalohippocampectomy with or without temporal lobe resection, multilobar resection and hemispherectomy.
Non resective surgery includes multiple subpial transections corpus colostomy and vagus nerve stimulation (VNS)
Ketogenic Diet in Epilepsy
High fat and low protein/carbohydrate diet given with/without a restricted fluid intake to maintain ketosis.
It can be used in all children above the age of 1 year with drug-resistant epilepsy.
Adverse effects include GI disturbances, acidosis, increased susceptibility to infections, drowsiness, weight loss, nutritional deficiencies and rarely, renal calculi and pancreatitis.
In failures it should be discontinued after in 3-6 months.
In responders, it should be continued for 2-3 year.
IN TONIC-CLONIC SEIZURE
DURING SEIZURE
Remain calm
Time the seizure episode
If child is standing or seated, ease the child down to the floor
Place pillow/ folded blanket below the child’s head.
Loosen restrictive clothing
Remove eye glasses
Clear area of any hazards or hard object
Allow seizure to end without any interference
If vomiting occurs, turn the head of the child to one side.
Do not attempt to restrain the child.
Do not put anything in child’s mouth.
Do not give any fluids or liquids.
After seizure
Time the post ictal period
Check the breathing. Check the position of head and tongue. Reposition if head is hyperextended
If child is not breathing give rescue breathing and call for emergency medical service.
Keep child on side
Remain with child
Do not give food or liquid until fully alert and swallowing reflex has returned.
Check head and body for possible injury
Check inside of mouth to see if tongue or lips have been bitten.
In complex partial seizure
DURING THE SEIZURE
Do not restrain
Remove harmful object from area
Redirect to safe area
Do not agitate; instead talk in calm reassuring manner
Do not expect child to follow instruction
Watch to see if seizure generalize.
PROGNOSIS
Prognosis for children with seizure depend on the etiology, type of seizure, age of onset, family and medical history. Risk factors associated with recurrence of epilepsy include:
Adolescent age and older
Family history of epilepsy
Frequent seizure on antiepileptic medication
Multiple antiepileptic therapy
Abnormal EEG
Seizure result from past injury/ insult.
NURSING DIAGNOSIS
1. Risk for Injury related to uncontrolled seizure activity (balance disorder).
2 .Ineffective airway clearance related to blockage of the tongue, endotracheal tube, increased secretion of saliva.
3. Social isolation related to low-self against the disease state, and the bad stigma against epilepsy in the community.
4. Ineffective breathing pattern related to dyspnoea and apnoea.
5. Activity intolerance related to decreased cardiac output, tachycardia.
6. Impaired sensory perception related to disturbances in nerve sensory organs of perception.
7. Anxiety related to lack of knowledge about the disease.
8. Risk for Ineffective cerebral Tissue Perfusion related to decreased oxygen supply to the brain.
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