GREAT LAKES UNIVERSITY OF KISUMU

FACULTY OF HEALTH SCIENCEDEPARTMENT OF CLINICAL MEDICINE

UNIT: PAEDIATRICS

TOPIC: CONVULSIVE DISORDERS

COURSE INSTRUCTOR : DR. KURIA M.STUDENT: KEVIN MMBIGURU

•Different types of seizures may occur in different parts of the brain and may be localized (affect only a part of the body) or widespread (affect the whole body).

•Seizures may occur for many reasons, especially in children. Seizures in newborns may be very different than seizures in toddlers, school-aged children, and adolescents

Characteristics of Seizure abrupt onset

brief duration (90-120 sec)

Altered mental status (except simple partial)

purposeless activity

unprovoked (except febrile)

postictal state (except simple partial and absence)

Although seizures have many known causes, for most children, the cause remains unknown.

In many of these cases, there is some family history of seizures.

The remaining causes include infections such as

Meningitis

developmental problems such as cerebral palsy

head trauma

Multiple sclerosis

Malaria

epilepsy

SEIZURES IN CHILDREN CAUSES

The most common type of seizure in children is the febrile seizure, which occurs when an infection associated with a high fever develops.Other reasons for seizures are these:

Metabolic disorders

Drugs

Medications

Poisons

Many yet undiscovered problems

febrile seizure A febrile seizure occurs when a child

contracts an illness such as an ear infection, cold, or chickenpox accompanied by fever. Febrile seizures are the most common type of seizure seen in children.

generalized seizure occurring during a sudden rise in temp in absence of intracranial infection or other defined etiology

Children who are developmentally delayed or who have spent more than 28 days in a neonatal intensive care unit are also more likely to have a febrile seizure.

One of 4 children who have a febrile seizure will have another, usually within a year.

Children who have had a febrile seizure in the past are also more likely to have a second episode.

Febrile Seizure: management ABCs and monitor VS

Check blood glucose

abort seizure if ongoing (benzodiazepine)

IV/IM/PR administration

Cooling measures

Neonatal seizures Neonatal seizures occur within 28 days of

birth. Most occur soon after the child is born. They may be due to a large variety of conditions.

It may be difficult to determine if a newborn is actually seizing, because they often do not have convulsions. Instead, their eyes appear to be looking in different directions.

They may have lip smacking or periods of no breathing.

Partial SeizuresSimple partial

Epileptic electrical discharge limited to focal area of cortex

Patients can interact normally with their environment except for limitations on localized brain function

Include subjective sensory and psychological phenomena

Auras affect about 60% of patients with focal epilepsy

Location of focus often predicts nature of pathology and directs testing

10

With motor signs Begin with clonic (rhythmic jerking) or tonic (stiffening)

movements in body part

Large cortical representation

involves muscles of face and hand “Jacksonian march” – uncommon

homunculus representation: begins in primary motor cortex and spreads to involve rest of precentral gyrus

“Fencer’s posture” – common

ictal discharges involve secondary motor areas of frontal lobe

contralateral flexion and elevation of arm, contralateral turning of head and eyes, and tonic expression of ipsilateral arm

11

Speech arrest, vocalizations, and eye blinking

Todd’s paralysis Transient neurologic abnormality – last <48

hours

Postictal depression of epileptogeniccortical area

motor seizure – focal weakness

sensory seizure – numbness

occipital lobe seizure – blindness

Focal abnormalities useful clues to site of origin

12

Complex Partial Impair consciousness and produce

unresponsiveness

70% to 80% arise from temporal lobe

Remaining cases arise mainly from frontal lobe

Many evolve from simple partial as progresses

Uncinate fits

preceded by olfactory aura

arise in or near uncus of temporal lobe

13

Convulsive seizures are noted by uncontrollable muscle jerking lasting for a few minutes-usually less than 5-followed by a period of drowsiness that is called the postictal period.

The child should return to his or her normal self except for fatigue within around 15 minutes. Often the child may have incontinence (lose urine or stool), and it is normal for the child not to remember the seizure.

Sometimes the jerking can cause injury, which may range from a small bite on the tongue to a broken bone.

Convulsive seizures

Tonic seizures result in continuous muscle contraction and rigidity, while tonic-clonic seizures involve alternating tonic activity with rhythmic jerking of muscle groups.

Infantile spasms commonly occur in children younger than 18 months.

They are often associated with mental retardation and consist of sudden spasms of muscle groups, causing the child to assume a flexed stature. They are frequent upon awakening.

Tonic seizures

Generalized seizures involve a much larger portion of the brain.

They are grouped into 2 types:

convulsive (muscle jerking)

non convulsive

Generalized seizures

Generalized convulsions. The child may undergo rhythmic jerking and muscle spasms, sometimes with difficulty breathing and rolling eyes.

The child is often sleepy and confused after the seizure and does not remember the seizure afterward.

This symptom group is common with grand mal (generalized) and febrile seizures.

Children with absence seizures (petit mal) develop a loss of awareness with staring or blinking, which starts and stops quickly.

There are no convulsive movements. These children return to normal as soon as the seizure stops.

Repetitive movements such as chewing, lip smacking, or clapping, followed by confusion are common in children suffering from a type of seizure disorder known as complex partial seizures.

Complications

Oral trauma

Vertebral compression fractures

Shoulder dislocation

Aspiration pneumonia

Sudden death – acute pulmonary edema, cardiac arrhythmia, suffocation

19

MOVEMENT SEIZURES

Movement seizures, which include partial seizures and generalized (grand mal) seizures, can be very dramatic..

If the child is on antiseizure medications, then the medication's levels in the blood are checked (if possible).

Children in status epilepticus are admitted to an intensive care unit.

If the child is doing well, doesn't have recurring seizures, and has a normal physical examination findings and blood test results, then the child will most likely be sent home to follow up with

Absence seizures, also known as petit mal seizures, are short episodes during which the child stares or eye blinks, with no apparent awareness of their surroundings.

These episodes usually do not last longer then a few seconds and start and stop abruptly; however, the child does not remember the event at all.

These are sometimes discovered after the child's teacher reports daydreaming, if the child loses his or her place while reading or misses instructions for assignments

ABSENCE SEIZURES

Atypical absenceMore gradual lapses of awareness

Not resolve as abruptly

Autonomic features or loss of muscle tone

Most often in mentally retarded children

Not respond as well to drugs

MyoclonicRapid, recurrent, brief muscle jerks

Can occur bilaterally, synchronously or asynchronously, or unilaterally without LOC

Often cluster shortly after waking or while falling asleep

22

Status epilepticus is either a seizure lasting longer than 30 minutes or repeated seizures without a return to normal in between them.

It is most common in children younger than 2 years, and most of these children have generalized tonic-clonic seizures.

Epilepsy refers to a pattern of chronic seizures of any type over a long period. Thirty percent of children diagnosed with epilepsy continue to have repeated seizures into adulthood, while others improve over time

STATUS EPILEPTICUS

Status Epilepticus: Considerations

Generalized convulsive activity results in: hypoxia

hyperpyrexia

BP instability and cerebral dysautoregulation

respiratory and metabolic acidosis

hyperazotemia/hypokalemia/hyponatremia

hyperglycemia followed by hypoglycemia

marked elevations of prolactin, glucagon, growth hormone and corticotropin

rhabdomyolysis may produce myoglobinuria and renal failure

Status Epilepticus: Management Rapid Seizure control

Step 1: ABC’s

NPA, OPA If rapid sequence intubation (RSI) needed use only short acting

paralytics

blood glucose Cardiac Monitor IV access HPI/PE

Further specific treatment based upon circumstance

Status Epilepticus: Management Step 2: 1st line drugs

Step 3: 2nd line drugs

Step 4: 3rd line drugs

The longer the seizure continues; The more difficult it is to stop

The more likely permanent CNS injury will occur

Medication Options First line

diazepam (Valium) IV/PR lorazepam (Ativan)IV/IN midazolam (Versed)IV/IM

Second line phenytoin/fosphenytoin phenobarbital

Lastly induction of anesthesia w. cont. EEG Infusions of midazolam, diprivan, valproic acid,

pentobarbital Inhaled isoflurane

CEREBRAL PALSY Disorder of movement acquired prenatally, perinatally

or in early childhood.

Secondary to brain insult (motor area or motor tracts).

Lesion non progressive.

Clinical picture non static (variable over time).

Aetiology:

Prenatal

Perinatal

Postnatal causes.

Aetiology:

Prenatal

Inherited disorders.

Intrauterine infections.

Cerebral malformation.

Toxic substances.

Aetiology:

Perinatal

asphyxia.

Prematurity.

Intracranial Trauma/ haemorrhage.

Neonatal seizures.

Kernicterus.

Infections.

Aetiology:

Postnatal

Infections like meningitis, encephalitis.

Encephalopathy.

Intracranial Trauma/ haemorrhage.

Metabolic disorders e.g dehydration.

Aetiology:

Incidence is variable, about 2:1000 children.

Higher rates in the under-developed societies.

In developing societies perinatal causes common.

Inherited causes in developed countries.

Classification/ Types:

Anatomical.

Physiological.

Functional

Classification/ Types:

Anatomical: based on limb involvement.

Hemiplegic

Diplegic

Quadriplegic

Paraplegic

Classification/ Types:

Physiological:based on tone of the muscles & associated activities.

Spastic cerebral palsy

Features include: increased muscle tone, brisk reflexes, upgoing plantar reflexes.

Hypotonic type.

Reduced muscle tone at rest but increased on activity.

Physiological.

Extra pyramidal: athetoid, choreo-athetoid movements.

Writhing movements predominate (with chorea

Associated with basal ganglia lesion.

Hyperbilirubinaemia and prematurity are known causes.

Deafness is common.

Classification/ Types:

Physiological.

Ataxic:

cerebellar dysfunction predominant.

Lack of balance and broad based gait.

Inco-ordination, hypotonia and nystagmus may occur.

Mixed type of any of the above features.

Diagnosis

Features in diagnosis include:

Cerebral insult.

Irritability.

Violent startle reaction.

Seizures.

Apathy, poor feeding.

Diagnosis - features

Floppy infant.

Stiffness.

Delayed motor milestones.

Stereotyped movements.

Micro- / macro-cephaly.

Strong hand preference in the first year.

Parental anxiety.

Associated Problems:

Seizures (occur in 25-35% of CP).

Mental retardation.

Specific learning disabilities.

Sleep disorders.

Hyperactivity.

Associated Problems:

Flexor spasms/ contractures.

Language deficit/ deafness.

Feeding difficulties/ constipation/ incontinence.

Infections esp resp. tract infection.

Misery/ distress to the family/ psychological problems.

Management

Counselling and health education to parents.

Treat the associated seizures.

Physiotherapy/ occupational therapy.

Surgery – Rhizotomies, tendon/ contractures release.

Management

Speech therapy.

Intellectual assessment for school placement.

Prognosis

Variable dependent on:

Rehabilitative resources.

Timing of rehabilitation.

Infrastructure.

Associated disorders / complications

Severity of lesion.