SEIZURE RECOGNITION, SEIZURE TYPES, FIRST AID

AND SAFETYCharuta Joshi MBBS, FRCPC

Director of pediatric epilepsyUIHC

ObjectivesAt the end of this lecture the participants will be able to:Define a seizure

Recognize different types of seizures

Define epilepsy

Know basic steps involved in seizure first aid

Name 2 different medications used on the site to treat seizures in the prehospital setting

Be familiar with ketogenic diet as therapy for seizures

What is a seizureSeizure recognition• A clinical manifestation of :• Abnormal• Excessive• Paroxysmal• Electrical discharge in neurons

Seizure recognition

• Stereotyped• Repetitive• If unsure video tape events• Ask pediatrician to see

Seizure recognition

• Spectrum of findings

Generalized seizures

Simple partial seizures

Complex partial seizures

Seizure recognitionsimple partial seizures• Localization

Seizure recognitionGeneralized• Absence• Myoclonic• Tonic• Generalized tonic clonic

How important is it to be sure about a seizure

First seizure clinic results

• 127 children• 94 were given diagnosis of epilepsy in first

seizure clinic• 36 had suffered at least one previous seizure

( 15 unrecognized by family as a seizure)• 31 – non epileptic events• Unclassified in 2

Differential diagnosis

Investigations after a first unprovoked seizure

Investigations

Yield of neuroimaging(Shinnar et al 2001)

What is epilepsy

• Tendency to have recurrent, unprovoked seizures

• 2 or more unprovoked seizures separated by 24 hours

Questions parents have after seizures

• Will it happen again?• How long do I have to wait for a recurrence?• Could my child die during a recurrence?• Could there be brain damage due to

recurrence• If medication treatment is delayed will there

be change in long-term chance of permanent remission?

Recurrence risks

• Recurrence rate at 2 years 40-50%

• Half the recurrences are within 6 months of initial seizure

• 80% of 5 year recurrence risk stabilizes by 2 years out

Risk factors for recurrence• Remote symptomatic etiology

• Abnormal EEG ( any spikes, generalized spike wave, focal or generalized slowing)

• Occurrence of seizure during sleep state (increases chance of recurrence)= lower morbidity than during daytime seizure

• Risk of recurrence after 2 seizures is 80%

Do you treat a first seizure

• Treatment reduces the risk of a second seizure by 50% at 2 years

• Immediate treatment DOES NOT reduce risk of long term seizures

• Treated and untreated groups have a 64% chance of 5 year remission at 10 years (MESS study)

• Risk of toxicity, allergic reaction, cognitive side effects

Risks of morbidity/ mortality due to seizures- could my child die??• 692 children in Nova Scotia ( Camfield 2002)• Followed =20 years• 26 deaths• 1 from status• 1 from SUDEP as an adult at age 22 years

Could my child die• Dutch study of childhood epilepsy ( Callenbach 2001) • 472 children followed for 5 years• 9 deaths• None from epilepsy• Connecticut study ( Berg 2004)• 613 children followed for 7.8 years• 13 deaths• 1=status• 1=SUDEP

When does immediate treatment matter• When risks of recurrent seizures outweigh

benefits of withholding treatment ( adults)• Cyanotic congenital heart disease in a child

Seizure first aid

• ABCs• Stay calm• Don’t leave patient alone• Lateral position if possible• Don’t restrain• Nothing in mouth• Call 911

Seizure safety

• Maximize quality of life• Water safety• Safety on roads• High structures• Medic alert, seizure beds, seizure dogs, baby

monitors

Seizure precautions

• Regular sleep• Alcohol• Infections• Photic stimulation• Substances of abuse Sports participation has not been shown to

increase risk of seizures

Prehospital treatment of seizures

Time definition of convulsive status

epilepticus

0 5 15 30

Most seizures stop

Operational definition of

status

Optimum time to start therapy

Medications used for prehospital treatment• Diazepam• Midazolam• Lorazepam

Prehospital treatment

midazolam

Lorazepam

• 2mg/ml Intensol• Indicated for anxiety

Faves…

Moving on to a different discussion now…

Ketogenic diet

• UIHC= The only center in the state • 30-40 active patients• Dedicated dieticianKarla Mracek• Dedicated ARNPTiffany Rickertsen

Historical anecdotes

History• Mac Fadden 1899- magazine

Physical Culture• Medical profession= Organized

fraud• People who follow MacFadden’s

rules would live to 120 years• Since much of the body’s energy

is wasted in digesting food, if no food is provided, more energy can be applied to recovering health

• Dr Conklin-osteopath in Battlecreek , Mi

• Used diet in epilepsy

Mr MacFadden• Physical culture

Historical anecdotes

• Conklin’s work( intestinal epilepsy- toxin release from glands= seizures)

• Conklin’s fast 18-21 days ( or as long as they could stand it)

Historical anecdotes

• Dr Geyelin worked at Johns Hopkins= confirmed Conklin's findings

• Dr BJ Wilder= fat can be used to break fast= no seizures

Charlie foundation

Charlie Foundation• Mr Jim Abrahams • Sought help from Johns

Hopkins for his son Charlie• Seizure free today after

several medications and neurologists

Movie

Since then…

Indications

Mechanisms of actionNot exactly known• Ketone bodies= antiepilepsy properties• PUFAs= membrane stabilization• Antioxidative/ antiinflammatory• Uncoupling of oxidative

phosphorylation( better energy utilization)

Types of ketogenic diet

• Classic ketogenic diet= 4:1 ratio• MCT oil diet ( less restrictive)• Modified Atkins diet=15-20 gm carbs/day• Low Glycemic index diet=60 gm carbs/day

Ketogenic diet

Most kids not fat… Results• 50-60% improve• Almost 100% improve –

Doose , GLUT1ContraindicatedFatty acid oxidation defect

Thank You !!