the seizing child
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Pediatric Seizures
Muhammad Waseem, MDMuhammad Waseem, MD
Emergency MedicineEmergency Medicine
Lincoln HospitalLincoln Hospital
Few things are more frightening to parents than to witness their child having a seizure
Objectives Wide spectrum of Pediatric seizure Etiologies specific to children Treatment modalities in children Quality of life issues Legal implications
Seizure Common neurologic disorder 3 - 5% of children 1/2 classified as febrile seizures Epilepsy (0.5 - 1%)
Seizure 10% ambulance calls for children 1.5% of total ED visit Most resolve in the pre-hospital
setting
Seizure - ED visits Febrile seizure 53% Established epilepsy 31% New-onset seizure 10% Status epilepticus 5%
Causes Idiopathic 76% Developmental 13% Infection 5% Head trauma 3% Other 2%
Seizure Fit Spell Attack Convulsion
What is Seizure?
Seizure Paroxysmal, time-limited event
that results from abnormal neuronal activity in the brain
Paroxysmal alteration in neurologic function (i.e, behavioral, motor, or autonomic function, or all three - volpe 1989.
Convulsion A seizure with prominent motor
manifestation
Epilepsy Disorder of CNS whose symptoms
are seizures Recurrent seizures Unprovoked
Seizure Most seizures are not epileptic Non-epileptic seizures are
physiologic Hypoxia Fever Toxins
Seizure Seizure is a symptom of a disorder
that need further investigations Does not constitute a diagnosis May occur in both normal &
abnormal tissue
Non-epileptic Events
Mimic Seizures Breath-holding spells Syncope Migraine Tics Night terror Pseudo-seizures
Non-epileptic Events Inaccurate diagnoses Inappropriate use of AED
Non-epileptic Events
Careful history
Breath-holding spells Frightening 6 months - 4 years Inciting event-Shrill cry-Breath
holding-Cyanosis Disappear spontaneously before
school age
Night Terrors 5 - 7 years Between midnight and 2 AM Slow wave sleep stage 3 or 4 Frightened and screaming Increased autonomic activity Sleep follows in few minutes No recall
Pseudo-seizure Diagnosis of exclusion 10 - 18 years Bizarre, unusual postures Verbalization Uncharacteristic movements Can be persuaded to have an
attack on request
Pseudo-seizure Lack of cyanosis Talking during seizure Normal reaction to pupil No loss of sphincter control Normal plantar responses Lack of post-ictal drowsiness Poor response to AED
Seizure First step in identifying the
epileptic syndrome is correctly identifying the type of seizure
Why Should I know type of Seizure?
Seizure Clue to cause Appropriate treatment Prognosis
Epileptic Seizures Partial (40%) Generalized Unclassified
Partial Seizure Simple Partial Complex Partial Partial with secondary
generalization
Generalized Convulsive Non convulsive
Absence Seizure
Generalized- Convulsive Myoclonic Clonic Tonic Tonic-clonic Atonic
Simple Partial Seizures (SPS) Consciousness not altered Aura Motor activity (face, neck or
extremity) “Feeling funny” or “something
crawling inside me” No post-ictal phenomenon
Complex Partial Seizures (CPS) Impairment of consciousness Aura Brief blank stare or sudden
cessation or pause in activity Automatism (lip smacking,
chewing, swallowing and excessive salivation)
Complex Partial Seizures (CPS) Dystonic posturing, tonic or clonic
movement Postictal phase Duration 1 - 2 minutes Usually during waking hours
Absence Seizure Sudden cessation of motor activity
or speech Blank facial expression Flickering of eye lids
Absence Seizure Uncommon before age 5 year Girls No Aura No postictal state Rarely persist longer than 30 sec
Absence Seizure Hyperventilation induces an
absence seizure 3/sec spike on EEG
Myoclonic Quick muscle jerks Loss of body tone Consciousness usually unimpaired Specific epilepsy syndromes
Tonic Tonic spasms of truncal & facial
muscles Flexion of upper extremities Extension of lower extremities
Clonic Resembles myoclonus Loss of consciousness Slower
Tonic-clonic Extremely common Begins suddenly without warning Tonic contraction of the trunk Rhythmic clonic contraction
alternating with relaxation of all muscle groups
Marked increase in HR and BP incontinence
Tonic-clonic Seizure last 1 to 2 minutes Post-ictal 30 minutes to 2 hours
Atonic Seizures Suddenly dropping to the floor Lanox-Gastaut syndrome Can occur without LOC
Case 1
Case 1 9-year-old boy Parents were aroused one night by
noise from his bed room Noted bed sheets awry &
breathing deeply bitten his tongue
Case 1 Confused Afebrile
First Non-Febrile Seizure
History Was this a true seizure or a non-
epileptic event?
History Circumstances
Normal activity vs. provoked Upon awakening
Duration Aura Abnormal motor movements Abnormal eye
movements/automatism
History Post-ictal period Urinary or fecal incontinence Fever, trauma or drug Birth history Delayed milestones Family history of seizures
Physical Examination Vital signs Level of consciousness Head circumference (percentile)
Always undress and examine the child
Café-au-lait spot Uniformly hyper-pigmented sharply demarcated macules Normal children (1-3 spots) 10% of normal children May be present at birth or develop
later
Neurofibromatosis (NF-1) Six or more, >5 mm in prepubertal Six or more, >15 mm in
postpubertal Crowe sign
freckled appearnace in axilla
Neurofibromatosis (NF-1) Present in 100% of patients present at birth Increase in size, number &
pigmentation Predilection for trunk & extremities Spare face
Lisch nodules Pigmented hamartomas of the iris NF-1 Prevalence increases with age
5% (<3 years) 42% (3-4 years) 100% (21 years)
Lisch nodules Asymptomatic Do not correlate with the extent &
severity Do not occur in normal individuals Best identified with slit lamp
Adenoma Sebaceum Erythematous papules over nose &
malar areas Develop between 4 and 6 years of
age coalesce & assume fleshy
appearance Tuberous sclerosis
Ash-leaf spots Hypo-pigmented Irregular borders May be present at birth Detectable by 2 years in 50% Wood’s ultraviolet lamp
Shagreen patch Roughened raised lesion Orange-peel consistency Primarily lumbo-sacral area
Tuberous Sclerosis Infantile spasm Hypsarrhythmic EEG pattern
CT Scan Periventricular calcifications
MRI Multiple cortical tubers
Port-wine stain Macular cutaneous nevus Present at birth Always involves upper face & eye
lids unilateral Sturge-Weber Disease
Port-wine stain Tonic clonic seizure contralateral
to the side of facial nevus Refractory to anticonvulsant hemiparesis
CT Scan Normal at birth Gyriform contrast enhancement Hemispheric atrophy Parenchymal calcification
Railroad track
Physical Examination Café-au-lait spots (NF) Adenoma sebaceum (TS) Facial hemangioma (Sturge-
Weber) Petechiae (meningitis)
Physical Examination Hematoma or skull fractures Signs of raised ICP Retinal hemorrhages (Child abuse) Signs of meningeal irritation
Diagnostic Evaluation Bedside glucose Serum Ca & Mg (< 3 months old) Urine drug screen CT head Outpatient EEG
Rolandic Epilepsy
Benign Partial Epilepsy with Centrotemporal Spikes (BPEC)
Rolandic Epilepsy Common in childhood 2 - 14 years Peak age 9 -10 years Normal children Unremarkable past history Normal neurologic examination
Rolandic Epilepsy Simple partial seizure 3-13 years (peak 9-10 years) Almost always at night (75% sleep) EEG (centrotemporal spike) Carbamazepine Excellent prognosis Spontaneous remission by age 15
year
Infantile Spasm (West’s synd) Sudden jerks of group of muscles 4-12 months Characteristic EEG
(hypsarrhythmia) Poor prognosis ACTH/Steroid
Case 2
Case 2 7-month-old boy with runny nose
and fever. His pediatrician saw him & diagnosed URI. He received tylenol. On the same afternoon while sitting on his mother’s lap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted approx 5 minutes
Case 2 He fell asleep after the seizure. Normal development T 102 F, HR 124, R 30 BP 90/50 Wt 7.9 Kg (50%) Ht 66.5 cm (50%) HC 44 cm (50%) No NC lesions
Febrile Seizures
Febrile seizures Most common type of seizures in
the pediatric age usually benign Can cause considerable parental
anxiety
Febrile seizures Seizures that occur in infancy or
childhood usually occurring between 3 months and five years, associated with fever, but without evidence of intracranial infection or defined cause
Febrile Seizures Age dependent Rare before 9 months & after 5
years Peak age 9-20 months Incidence 3 - 4% Family history Diagnosis of exclusion
Febrile Seizures Risk factors
Height of temperature Male sex Family history of febrile seizure
Febrile Seizures A family history of epilepsy has not
been shown to be a risk factor for first febrile seizures
Febrile Seizures Risk factors for recurrence
Young age at onset Febrile seizures in first degree
relative Lower degree of fever
Febrile Seizures Generalized tonic-clonic Duration few seconds to 10
minutes Excellent prognosis 20% are complex
Febrile Seizures Complex febrile seizure
> 15 minutes More than once in 24 hours Focal neurologic features
Febrile Seizures Risk of recurrence 34% Most recurrences within 6-12
months
Lumbar Puncture The decision to perform LP should
be based on the age of the child at presentation (AAP)
Lumbar Puncture < 12 months
Strongly recommend 12 - 18 months
Should consider > 18 months
If history & physical examination suggest intracranial infection
Febrile Seizures Signs of meningeal irritation
Unreliable under 18 months
Red flags Focal seizure Suspicious physical examination
findings (eg, rash, petechiae) cyanosis, hypotension, or grunting
Abnormal neurologic examination
Febrile Seizures Meningitis must be ruled out
Difficult if the patient is on antibiotics
Febrile Seizures Determine and treat the cause of
fever IV benzodiazepine Rectal diazepam No routine AED prophylaxis
Febrile Seizures Incidence of epilepsy
1% (No other risk factor) 9% (Other risk factors)
Epilepsy Family history of later epilepsy Preexisting neurologic abnormality Complex febrile seizure
> 15 minutes duration > 1 febrile seizure per 24 hour
Focal febrile seizure
Neonatal Seizures
Neonatal Seizures Seizures during first 28 days 0.5% of all live births Do not indicate epilepsy
Jitteriness Vs Seizure Movements are stimulus sensitive Appear during active state (crying) Disappear on passive flexion Not jerky No abnormal eye movements
Neonatal Seizures Neonates are at particular risk
Metabolic Toxic Structural Infectious
Neonatal Seizures Not generalized tonic-clonic
incomplete myelination Can be very subtle Minimal physical findings
Neonatal Seizures Subtle Tonic Clonic Myoclonic
Subtle Seizure More common in premature infants Eye deviation + jerking eyelid blinking fluttering smacking or drooling Apneic spells
Causes Perinatal asphyxia Intracranial hemorrhage Metabolic - hypoglycemia,
hypocalcemia Infections Drug withdrawl
History Family history
metabolic Maternal drug history Delivery
Mode & nature of delivery Fetal intrapartum status Resuscitative measures
Physical Examination Gestational age Blood pressure Presence of skin lesions Presence of hepatosplenomegaly Neurologic evaluation
Lab Serum chemistry Spinal fluid Metabolic work-up
serum ammonia amino-acids
Lab Head sonogram
IVH/periventricular CT head
Hemorrhage Calcifications Malformations
EEG
Management The method of treatment depends
on the cause Anticonvulsant
Phenobarbital
Status Epilepticus
Status Epilepticus Seizure >30 minutes Intermittent seizures longer than
30 minutes from which the patient does not regain consciousness
Status Epilepticus (SE) Highest incidence in very young
children 5% of ED visit of seizing children 70% of children with epilepsy
experience at least one episode of SE
Mortality rate 8 to 32%
Status Epilepticus (SE) Any type of seizure Generalized (most common) Absence or partial (10%) Febrile SE (25%)
Life-threatening causes Bacterial meningitis Hypoglycemia Increased intra-cranial pressure Hypoxemia Toxins
TCA, Cocaine, Theophylline, insulin
Management Rapid stabilization of cardio-
respiratory functions Termination of both clinical &
electrical seizures Diagnosis & treatment of life
threatening precipitant
Status Epilepticus “The child is often given too much
IV benzodiazepine….Blood gases are measured and perhaps the values are found to be slightly decreased. The child is then paralyzed, intubated, and sent to the intensive care unit to recover from the iatrogenic morbidity.”
Status Epilepticus Freeman JM: Status epilepticus: It’s
not what we’ve thought or taught. Pediatrics 1989;83:444-445
Status Epilepticus Primary goal is to stop the seizure First line (benzodiazepine) Second line (phenytoin or
fosphenytoin)
Diazepam Rapid onset (3 - 5 minutes) Orally, IV, IM, IO or Rectal Duration of action 20 - 30 minutes Respiratory depression, sedation,
hypotension Diastat (rectal gel)
Diazepam IV 0.1 - 0.5 mg/kg Rectal 0.2 - 2 mg/kg
(maximum 10 mg)
Lorazepam Slower onset Longer duration (12 - 24 hours) Orally & IV Inappropriate for rectal administration 0.05 - 0.2 mg/kg “Must be refrigerated” Tachyphylaxis
Phenobarbital Long duration (24 hours) IV 10-20 mg/kg bolus
rate 1-2 mg/kg/min Intubation (>30-40 mg/kg) Respiratory depression,
hypotension & bradycardia
Phenytoin 1950 - Massachusetts General Hospital
pH 12, limited solubility in waterPropylene glycol & ethanol
1956 - Parenteral formulation approved 1962 - pediatric dose recommendation 1986 - Revised Pediatric dose
(15-20 mg/kg, 1-3 mg/kg/min)
Phenytoin High pH
Burning & cutaneous reactions Purple glove syndrome
Phenytoin Propylene glycol
Seizures Arrhythmia Asystole Hepatic & renal damage Hemolysis Hyperosmolality Lactic acidosis
Phenytoin The amount of propylene glycol in
a typical loading dose of phenytoin administered to a 1 kg premature neonate is about seven times greater than WHO standard
Fosphenytoin 1996 Pro-drug of phenytoin pH 8 Far more soluble in water No organic solvent Both IV & IM Rapid & complete conversion to
phenytoin
Sports Participation
Sports Participation Unnecessary restrictions Successful athelete with epilepsy
Gary Howatt (hockey player)
Sports Participation Which sport “Common sense” Significant metabolic imbalance
Scuba diving Potential for serious injury
AMA Committee for Sports “Patients with epilepsy will not be
affected by indulging in any sport, including football, provided the normal safegaurds for sports participation are followed, including adequate head protection”
Permitted Sports Baseball basketball broad jumping hockey gymnastic Soccer wrestling
Reasonable precautions Bicycling Diving Football Skating Swimming
Prohibited Sports Boxing Bungee jumping Polo Scuba diving Skydiving Waterskiing
Driving & Regulatory Issues
Driver Licensing Each state has its own regulations “Seizure free period”
1 Year (NY)
Reporting responsibility Patient responsibility (most
states) Physician responsibility (Six
states) CA, DE, NE NJ, OR, PA
Employment
Employment Average intelligence Good health Unpredictable loss of
consciousness
Employment No hard-and-fast rules Should avoid workplaces in which a
sudden loss of consciousness may expose them or their coworkers to risk or injury
Employment Interstate truck Forklift Working in heights
Pregnancy & Epilepsy
Pregnancy & Epilepsy 20,000 births women with epilepsy Lower seizure threshold
Offspring & AED
Offspring & AED Pheytoin
fetal hydantoin syndrome Valproate
neural tube defect Carbamazepine
spina bifida
Labor & Delivery
Labor & Delivery Bleeding tendency in neonate
induction of hepatic enzymes overcome by Vitamin K
Breast feeding & AED
Breast feeding & AED Nearly all epileptic drugs are
transferred in breast milk Phenytoin 18% Phenobarbital 36% Carbamazepine 41% Valproate 5% Breast feeding is not contraindicated
Oral contraceptives & AED
Oral contraceptives & AED Increase the dose of Oral
contraceptives (AED induces hepatic
metabolism of hormones)
Don’t forget child abuse
Discrepancy between history & injury
“You are mandated by law to protect these children”
It’s not optional New York State Law (Social
Services Law Section 413) requires that any health professional who suspects that a child is being endangered or maltreated must report his/her suspicion to NY City, to the local child protection services
New AED’s
New AED’s Gabapentin (Neurontin) Lamotrigine (Lamictal) Vigabatrin (Sabril) Felbamate (Felbatol)
Take home message Wide range of presentation Efficiently obtain information Always undress & examine Establish underlying etiology Suspect abuse with inconsistent
history