childhood seizures and epilepsy for medical students
DESCRIPTION
a lecture about childhood seizures and epilepsy target: Medical student, Family medicine physicians, GPTRANSCRIPT
By Dr. Hussein Abdeldayem, MD Head & Professor of Pediatric Neurology Unit Faculty of medicine, Alex University
Childhood Seizures in ER :Management
Case
• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation
ER/Seizures
• Seizure in children is one of the most anxiety-provoking conditions for parents and a coon reason for �emergency department visits, especially if the seizure is of new-onset or the child is not on anti-epileptic medication
• Anti-epileptic drugs should not be routinely initiated in the emergency department in children whose seizures have resolved
ER/Seizures (cont.)
Seizure ?
Epilepsy ?
Seizure : the involuntary clinical manifestation (S &/or S)
due to an abnormal and excessive excitation and synchronization of a population of cortical neurons
Epilepsy
Number ??? Time onset??
? FC, ? tetany
More than oneMore than one
More than one day apartMore than one day apart
unprovocativeunprovocative
EPILEPSY
Seizure is an Seizure is an ACUTE ACUTE ManifestationManifestation
Epilepsy is a Epilepsy is a Chronic Chronic DISEASEDISEASE
Is it Seizure?
How do u treat acute seizure?
What is the type of seizure?
PATHOGENESIS OF SEIZURES
Mechanisms of Seizures
• Defective balance between excitatory and inhibitory neurotransmission
+VE -VE
Mechanisms of Seizures
• Defective balance between excitatory and inhibitory neurotransmission
+VE
-VE
+-
classification
• Aetiology• CP• EEG
EPILEPSYAetiology
• Idiopathic
• Symptomatic (Acquired)
• cryptogenic
• Genetic
• Structural (acquired)*
• Unknown
* More in neonates and infancts
1985 2010
Aetiology # Age
• Before age 2: Developmental defects, birth injuries, CNS infections and metabolic disorders
• Ages 2 to 14: Idiopathic (genetic) seizure* disorders
• Adults: Cerebral trauma, withdrawal, tumors, strokes, and unknown cause (in 50%)
• The elderly: Tumors and strokes
genetic GTCChildhood Absence
General ActivityGeneral Activity
Focal ActivityFocal Activity
2-Classification according to EEG findings2-Classification according to EEG findings
Classification according to EEG findings
GeneralizedGeneralized FocalFocal
Both Cerebral Hemispheres
Only a part of a hemisphere
Loss of Consciousness No loss of consciousness
Treated by Valproate Treated by Carbamazipine
MRIMRI
Focal withFocal with 2ry G2ry G
Pediatric SeizuresSeizure Type Classification
3- Clinically (ILAE 1981)
GENERALIZED
1- Involves both cerebral hemispheres
2- Loss consciousness
2- EEG: generalized
3- no aura
FOCAL (PARTIAL)
1- involve one
hemisphere
2- NO Loss of consciousness
3- EEG: focal activity
4- ± aura
Partial (focal) with secondary generalizationPartial (focal) with
secondary generalization
± MRI
ASKASKMRIMRI
Generalized SeizuresGeneralized Seizures
Tonic-clonic
Which type of seizure is this ?
Generalized SeizuresGeneralized Seizures
Clonic
Which type of seizure is this ?
Generalized SeizuresGeneralized Seizures
Tonic
Which type of seizure is this ?
Generalize Spike Wave Discharge
Generalized Seizures
Generalized Seizures
Absence
VPA, ETX, LMTVPA, ETX, LMT
Which type of seizure is this ?
Absence seizures and EEG
EEG: Absence Seizure
EEG: classic 3/sec spike-and-wave especially with HV
Generalized Seizures
Generalized Seizures
Which type of seizure is this ?
Myoclonic
Atonic
Which type of seizure is this ?
Generalized Seizures
Generalized Seizures
Myoclonic
Atonic
Mixed
Absence
TonicClonic
Tonic-clonic
Generalized SeizuresGeneralized Seizures
VALPROIC ACID
(focal)(focal)
simplesimple
MotorMotor
Which type of seizure is this ?
EEG: Simple focal Seizure
EEG: Focal changes
Motor
Sensory
autonomic
psychic
Simple Partial (Focal) Seizures
Partial (Focal)
Complex partial
Which type of seizure is this ?
Complex Partial Seizure.flv
ComplexSimple
Partial (Focal) Seizures
2ry Generalization
Carbamazepine
Febrile Convulsions FCDefinition
• Age : between 6 months and <6 years of age
• with fever > 38 ํC ( rectal temperature)
• but without evidence of intracranial infection and no history of prior afebrile convulsion
Precipitating factors:
Precipitating factors: 1.1. Body Body Temperature:Temperature:
• Temperature ≥ 38 〬 C
• FC occur during 1st 24 hrs of the febrile illness
• Depends on the rapidity of the rise rather than the temperature itself
2. Infections & FC:
• VIRAL :VIRAL : UTRI, otitis media, roseola infantum
• Bacterial: gastoeneritis, pneumonia, UTI
• Post-Vaccinational: pertussis & measles vaccination
3. Genetic Factors:• Positive family history for febrile seizures.
• In most cases the disorder appears polygenic. I
n some families the disorder is inherited as an autosomal dominant traitautosomal dominant trait,
• Multiple single genes Multiple single genes causing the disorder have been identified, FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes:
• 8q13-q21
• 19p13.3
• 2q24
• 5q14-q15
• 6q22-24
• 18p11.2• 21q22.
Classification of FC
• Simple (typical) FC
• Complex (atypical) FC
Simple FC complex FC
• Constitute 80-85% of FCs
1- generalized tonic-clonic motor activity
2- less than 15 minutes with rapid return of consciousness.
3- not recurring more than once within 24hrs
4-no postictal neurological abnormalities
5- normal CNS child
• Constitute 15 – 20% of FCs
1-focal seizure manifestations
2-prolonged seizure activity exceeding 15 minutes
3- recurring more than once within 24 hrs
4- postictal neurological abnormalities
5- abn CNS : as CP
No EEGNO AEDNo EEGNO AED
EEGAED
EEGAED
Infantile Spasms
S Zaher IS.3gp
Which type of seizure is this ?
ACTH
VPACZPVGB
EEG finding:hypsarrhythmias
NEONATAL CONVULSIONSSubtle
2- eye1- APNEA
NEONATAL CONVULSIONSSubtle
3- oral
NEONATAL CONVULSIONSSubtle
4- UL 5- LL
History (9)
• First• Last• Frequency
• Aura • Ictal • Postictal
• duration• Investigation• Treatment
Practical Points
DURATION OF TREATMENT
2 years from last attack Withdraw over 3 months
VPA GENERALIZED FITS
PARTIAL FITS
CBZ
GENERALIZED FITS
PARTIAL FITS
Depakine (Valproate)
• 20 – 60 mg/kg/d• Twice*• FormsOral with dropperOral with spoon200 mg tablets500 mg chrono tablets• Follow up of:Serum drug level (peak)Serum drug level (trough)SGOT, SGPT, PT
Tegretol (Carbamazepine)
• 10 – 20 mg/kg/d*• Twice• Forms
Oral (100 mg/5ml)
200 mg tablets
200 mg CR tablets
400 mg CR tablets• Follow up of:
Serum drug level (peak)
Serum drug level (trough)
Blood CBC
Question for ALL
• For my pediatric epileptic patients, well controlled seizures are mostly through:
A- Monotherapy
B Polytherapy (2 drugs)
C- Polytherapy (3 or more drugs)
D- Other methods (?)
Seizures in E DSeizures in E D
Case
• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation
• prolonged seizures may result in neuronal injury, cell death, or both, and this becomes most pronounced after half hour or more of continuous seizure activity
• the earlier the therapeutic intervention, the
more likely one can terminate the seizure
Status EpilepticusStatus Epilepticus
• 30*** minutes of continuous seizure without regaining consciousness
• Two or more Seizures with Failure to regain consciousness Between Seizures (serial status)
Practical SE
• If a seizure continues for more than 5 minutes or
• the patient has 2 or more generalized tonic-clonic seizures within 1 hour,
Aggressive management is warranted asthese patients progress rapidly to status epilepticus
Practical Status epilepticus
Generalized convulsive status epilepticus involves at least one of the following:
• Tonic-clonic seizure activity lasting > 5 to 10 min
• ≥ 2 seizures between which patients do not fully regain consciousness
Stay calm and manage effectively
Handling of the active
seizure
Never restrain the child or place anything in the mouth
Treatment
• ABCDs
• Specific treatment*
ABCDs
• Airway• Breathing• Circulation• Drugs
*Initial studies include glucose, serum chemistries (most importantlysodium, magnesium, calcium, phosphate, BUN), arterial blood gas, AED levels (if applicable), CBC
Lorazepam (ativan) 0.1 mg/kg
Diazepam 0.3 mg/kg*
PR diazepam 0.5 mg/kg
• In infants less than 24 mo of age, intravenous pyridoxine (100–200 mg) should be considered.
Rectal Diazepam*
• The absorption of oral diazepam is slow (1-2 hours) and variable.
• Intramuscular diazepam has similar absorption problems, is painful and may cause muscle necrosis.
• Suppositories have slow and variable absorption rates and are not recommended in an emergency.
Rectal administration of the intravenous form of diazepam
Rectal Diazepam*
• Intravenous and rectal diazepam both stop seizures in more than 80% of cases within 10-15 minutes
Less Resp Depression
Less BP Depression
Less CNS Depression
Prolonged action
Rectal Diazepam
• Use IV ampoules (10mg/2ml) or gel• Use Insulin syringes*• Rectal administration (use lubricant)
Dose: 0.5 MG/KG max: 10 mg
Lubrication
Diazepam adsorbs to plastic and thus needs to be stored in glass
3
The following statements are either true or false
• Rectal diazepam is the treatment of choice for status epilepticus.
• 2. Oil in water emulsions of injectable diazepam are inappropriate for rectal administration.
False
True
Timed treatment
• 0 – 5 min ABCD*• 5 -10 min BZD IV x2• 10-20 min DPH or PB IV• 20-30 min PB or DPH IV• >30 min midazolam IV continuous
infusion**• 40–60 min ICU, anesthesia, EEG
Give the Diagnosis
Seizure pretenders
• • Paroxysmal nonepileptic disorders that
may be mistaken for seizures include syncope, breath holding spells, sleep disorders, migraine headaches, apparent life threatening events (ALTE), and pseudoseizures
Thank youThank you
Case (cont.)
• You are called to the bedside and after 5 minutes, these movements have not stopped.
• Options for your next course of action are:
1- continue to wait for the spell to subside
2- administration of IV diazepam
3- administration of IV phenytoin
4- administration of IV phenobarbitone