neonatal seizures
TRANSCRIPT
NEONATAL SEIZURESSHINU K ANTONY
1ST YEAR MSc NURSING
DEFINITION
Neonatal seizures are the seizures that occur within the first 4 weeks of life and are most commonly seen within the first 10 days.
INCIDENCE
57.5/1,000 in infants with birth weights <1,500g
2.8/1,000 in infants weighing between 2,500 and 3.999g have seizures.
1 in 200 healthy newbornsMany seizures are very subtle – go undetected
MECHANISM
1.Large group of neurons undergo excessive, synchronized depolarization which results from –
a) Increase in excitatory neurotransmitters (glutamate)
b) Decrease in inhibitory neurotransmitters (gamma amino butyric acid- GABA
MECHANISM
c. Disruption of ATP – dependent resting membrane potentials - Failure of Na - K pump – flow of sodium into the neuron & potassium out of neuron d. Membrane alteration - Increased Na permeability
HYPOTHESIS
Inhibitory neurons are selectively damaged and remaining principal excitatory neurons became hyper excitable
Aberrant excitatory circuits are formed as a part of re organization after injury
In neonates
Immature brain has more excitatory neurons than matured (excitatory glutamate containing circuits)
GABA has a paradoxical excitatory nature in immature brain
Additionally GABA sensitive substantia nigra pars reticulata neurons play a part in preventing seizures, but in neonates it is immature
ETIOLOGY
PERINATAL ENCEPHALOPATHY
METABOLIC
INBORN ERRORS OF METABOLISM
ETIOLOGY……
INFECTIONS
DEVELOPMENTAL DISORDERS
DRUG ASSOCIATED SEIZURES
ETIOLOGY…….
THROMBOTIC DISORDERS
BENIGN FAMILIAL NEONATAL SEIZURES
HYPERTENSIVE ENCEPHALOPATHY
ETIOLOGY……
UNKNOWN OR IDIOPATHIC
HYPOXIC ISCHEMIC ENCEPHALOPATHY
Primary neuronal injury: intracellular energy failure occurs, resulting in immediate cell death by necrosis
Secondary neuronal injury occurs hours or days after the orginal insult
CLINICAL CLASSIFICATI
ONS
FOCAL CLONIC SEIZURES
Localized clonic jerking of one limb with no loss of consciousness.
The electroencephalography is unifocally abnormal .
Prognosis good. Metabolic disturbances like
hypocalcemia, cerebral contusion, focal infarct, or subarchinoid hemorrhage.
MULTIFOCAL CLONIC SEZURES
More in term infants. Characterized by random clonic
movements of limbs. Many muscle groups are involved simultaneously.
The EEG is multifocally abnormal.The prognosis is variable metabolic abnormalities like
hypoglycemia,and hypoxic-ischemic encephalopathy
TONIC SEIZURES
Seen in preterm neonates. May mimic decerebrate or decorticate
posturing. They are often associated with eye deviation, clonic movements or apnea.
The EEG is multifocally abnormal with a burst,suppression pattern or can have extremely attenuated amplitude.
The prognosis is generally poor.With diffuse cns disease or intraventricular
hemorrhage
MYOCLONIC SEIZURES
Synchronous single or multiple jerks of upper or lower limbs.
Involves distal muscle groups. The EEG shows burst-suppression pattern
or focal sharp transient waves leading to hyporrhythmia.
Diffuse cns pathology,and development defects like anencephaly.
The prognosis is poor.
SUBTLE SEIZURES
Most common type (>50%)of neonatal seizures.
They can be varied in nature and manifest variously
The EEG is often not associated with an epileptiform or hypersynchronous EEG.
They are now considered to be brainstem release phenomenon and not seizures.
Electroencephalographic Classification of Neonatal
Seizures
Clinical seizure with a consistent EEG event
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BENIGN SEIZURES
‘fifth day seizures’Benign sleep myoclonus
These are seizures occurring in well babies and all investigations are negative. Causes are
SL
NO
:
CLINICAL
FEATURES
JITTERNESS SEIZURES
1 Abnormal gaze or eye
movement
Nil Present
2 Movements Exquisitely stimulus-
sensitive
Spontaneous
3 Movements cease Passive flexion or
gentle restraint
On their own
4 Predominant movement Tremor Clonic jerking
5 Fast and slow components Absent Present
6 EEG Normal Abnormal
7 Rate or jerks 5 to 6 per second 2 to 3 per second
8 Blood pressure, heart rate Normal Increased
HISTORY
ANTENATALINTRANATALPOSTNATALFAMILY HISTORY OF SEIZURES OR
NEONATAL DEATHSNEUROCUTANEOUS MARKERS
Investigations
CBCBlood – glucose, calcium, Na, K, Mg,
bilirubin, ABG, LFTCSF analysisBlood C/S , urine C/SCranial USG
Second line investigations
TORCH screeningIEM screening – urine organic acids - S. amino acid assayMetabolic disorders – s.ammonia, ABG
Investigations….
Imaging – CT scan - MRI - EEG brain:Routinue neonatal
EEG recording, Amplitude integrated EEG (aEEG)
Management
Collect all samples IV lineThermoneutral environmentGlucose 10% - 2-4ml/kg as bolus followed
by 10% glucose as drip @ 8mg/kg/minIV calcium – gluconate 2ml/kg
Management…..
If significant seizures persists, midazolam 0.15mg/kg IV bolus followed
by IV infusion 0.1-0.4mg/kg/hr (0.2-0.6mcg/kg/min).
sodium valporate IV is the usual next drug in case of resistant seizure (20-25mg/kg/day).
Vigabatrin (50mg/kg/day) and topiramate (3mg/kg) are experimental at present.
Further management
Maintenance dose of anticonvulsants is started 12hours after loading.
Initial maintenance doses are given as intravenous and later switched over to oral.
If on multiple anticonvulsants and seizures free for 2-3 days then try to taper on to monotherapy
If controlled with calcium gluconate, start maintenancce dose
If the baby is seizures free after 1 or 2 episodes and with normal neurological status or there is a known cause for seizures then anticonvulsant may be stopped on discharge.
If the baby had difficult to control seizures or if baby is neurologically abnormal then anticonvulsants may be continued and consider a neurology consultation
ANTICONVULSANT DRUG DOSES
DRUG INITIAL DOSE MAINTENANCE
Phenobarbital 20mg/kg IV. Consider further 5-10mg/kg
increments to a total of 40mg/kg
Check drug levels may not
need further doses for many
days 3-4 mg/kg/day
Phenytoin 20mg/kg IV. Fosphenytoin 20mg /kg IV 3-4mg/kg/day divide bid to
qid
benzodiazepines Lorazepam 0.05-0.1 mg/kg IV. Diazepam
0.3mg/kg IV
INITIAL MANAGEMENT OF ACUTE METABOLIC DISORDERS
Hypoglycemia Dextrose 10% 2-3ml/kg IV
Hypocalcemia Cacium gluconate 5% (50mg/ml), 100-200mg/kg IV 10%
(100mg/ml) 50-100mg/kg IV if inadequate time for dilation
Hypomagnesemia Magnesium sulphate 12.5% (125mg/ml) 50-100mg/kg IV
Hyponatremia Furosemide 1mg/kg IV. 3% Na Cl 1-3ml/kg over 15to 30 mts
PROGNOSIS AND OUTCOME
Level of maturationMetabolic abnormalitiesSevere grades of IVH and congenital malformations
Seizure patternEEG
National Collaborative Perinatal Project
Apgar <=6 at 5 minutes or longerThe need for positive pressure ventilation > 5
minutes after birthEarly onset of seizures within 24hrsHypotonia at 5mts or longer following birth3 or more days with uncontrolled seizuresPresence of tonic or myoclonic seizuresSeizures lasting longer than 30mtsNeed of more than one anticonvulsant drug for
control of seizures
NURSING
MANAGEMENT
NURSING ASSESSMENT
Health historyPhysical examination
NURSING DIAGNOSIS
Decreased intracranial adaptive capacity related to compression of brain tissue due to increased intracranial pressure resulting from brain injury
Risk for ineffective (cerebral;) tissue perfusion related to increased ICP alteration in blood flow secondary to hemorrhage, vessel malformation or edema
NURSING DIAGNOSIS……..
Risk for injury related to altered level of consciousness, weakness, loss of muscle coordination secondary to seizure activity
Disturbed sensory perception related to presence of neurologic leisions or pressure on sensory or motor nerves secondary to increased ICP as evidenced by nystagmus, loss of response to stimuli
NURSING DIAGNOSISI……
Risk for infection related to surgical interventions, trauma to brain, stasis of pulmonary secretions and urine
Imbalanced nutrition less than body requirement related to vomiting and difficulty feeding
BIBLOGRAPHY
John Cloherty P, Eric Eichenwald C, Annie, Hansen R, Ann Stark. Manual of neonatal care.7th ed. South Asia: Lippincott, Williams and Wilkins; 2012
Santhosh Kumar A. manual of newborn care. 2nd ed. Newdelhi: Paras medical publishers; 2011
Dipak Guha K. Guha’s Neonatology: Principles and Practice. 3rd ed.Jaypee publication.
Dorothy Marlow R, Barbara Redding A. Text Book of Paediatric Nursing. 6th ed. Elsevier publication.
David Wilson, Marilyn Hockenberry J.Wong’s Clinical Manual of Paediatric Nursing. 8th ed. Elsevier publication.
Kliegman, Stauton, Geme S T, Schor, Behrman. Nelson’s Textbook of Pediatrics.Vol II 19th ed. Philadephia:Elsevier publishers.2012
Maggie Meeks, Maggie Hallsworth, Helen Yeo. Nursing the Neonate. 2nd ed. Wiley Blackwell publication.
Terrikyle, Susan Carmar. Essentials of Pediatric Nursing. 2nd ed. Phiadephia: Wolters Kluwer Health publishers.2010