19: 16-month-old male with first seizure Flashcards
1
Q
Causes of Unresponsiveness in Children: toxic ingestions
A
–Most commonly seen in children between the ages of 9 months and 3 years of age.
–Various medications can lead to a state of unresponsiveness.
–Some of the more common medications would be opiates, benzodiazepines, and clonidine.
–Other considerations would be medications that can cause a metabolic disturbance (e.g., oral diabetic agents causing hypoglycemia.
–A careful history must be taken about all medications in the child’s house and other homes where he or she spends time (grandmother’s home, babysitter’s home, etc.).

2
Q
Causes of Unresponsiveness in Children: Seizure
A
- -Seizures are common in children.
- -Best described as paroxysmal neurologic events and have variable forms of presentation, such as generalized or partial seizures.
- -Seizures can have many causes, from metabolic disturbances (hypoglycemia or hypocalemia) to head trauma resulting in cerebral contusion or intracranial hemorrhage.
- -Children with developmental abnormalities of the brain or genetic syndromes which involve the brain (e.g., tuberous sclerosis) may also have seizures.
- -In many children, seizures may be idiopathic.
- -Some children have only one seizure in their lifetime; others will have recurrent seizures and thus be given the diagnosis of epilepsy (typically classified as two or more unprovoked seizures).
- -Epilepsy (all forms) has a prevalence of approximately 1% throughout childhood.
- -Even in the absence of a seizure, other important neurologic causes should be
3
Q
Causes of Unresponsiveness in Children: Syncope
A
- Syncope due to breath-holding spells is common in children 1-3
- Breath-holding spells are classified as either cyanotic or pallid type.
- In the more common cyanotic type, the key historical feature is a precipitating event that upsets the child, resulting in vigorous crying and hyperventilation, followed by a prolonged expiratory apnea; transient hypoxia results in the child turning pale or cyanotic, followed by brief loss of consciousness and limpness.
- The episodes quickly self-resolve and there is typically no associated post-ictal state.
- Occasionally, a child with a breath holding spell may have a brief generalized seizure, most likely due to hypoxia.
- For the most part, parents should be reassured that breath-holding spells are a benign and self-limited condition.
- Very rarely, breath-holding spells have been reported to be associated with asystole.
- Cardiac syncope is a bit more unusual in a child of infant or toddler age, but should be considered; it would most likely not be vasovagal type syncope.
- However, cardiac causes such as supraventricular arrhythmias (supraventricular tachycardia) or ventricular arrhythmias (in the setting of prolonged QT syndrome) can decrease cerebral blood flow and cause syncope.
4
Q
Causes of Unresponsiveness in Children: Closed Head Injury
A
- Closed head injury (with or without intracranial injury) may lead to loss of consciousness.
- The family or caregiver may not have witnessed the traumatic event.
- Should there be indications in the history; inflicted head trauma should also be considered as a possible diagnosis.
5
Q
Causes of Unresponsiveness in Children: Infection
A
- Up to 30-40% of children with meningitis can present with seizure activity.
- Fever and irritability may be the only signs seen on exam.
- Children with encephalitis will frequently present with waxing and waning mental status, as well as fever and seizure.
- After the seizure is over, children with meningitis or encephalitis typically do not return to baseline activity and remain impaired.
- Enteroviral infections and herpes simplex virus should be considered as possible pathogens for encephalitis.
6
Q
Causes of Unresponsiveness in Children: Intracranial Process (less common 1/2)
A
- Brain tumor can lead to both seizures or more global alterations in mental status.
- The patient’s medical history might include a preceding history of headache, behavior change, vomiting, or focal neurologic change.
- Brain tumors are the most common solid tumors in childhood (approximately 1,200 cases per year) and usually occur in the posterior fossa.
7
Q
Causes of Unresponsiveness in Children: Intussusception (less common 1/2)
A
- -Intussusception is the telescoping or prolapsing of a portion of the intestine within another immediately adjacent portion of intestine-usually the terminal ileum into the colon.
- -Repeated episodes of colicky pain are the classic presentation of intussusception.
- -As the condition becomes more long-standing, lethargy with a near unresponsive state can be seen between the episodes of colicky pain.
- -In addition, children with intussusception commonly have intravascular volume depletion due to vomiting and third spacing of fluids; this may lead to mental status changes similar to a child who is very dehydrated.
8
Q
Generalized tonic-clonic seizure
A
- This is the most common type seen in children.
- The event typically begins abruptly with tonic (rigid) stiffening of all extremities and upward deviation of the eyes.
- Clonic jerks of all extremities follow the tonic phase.
- Finally, the child becomes flaccid, and urinary incontinence may occur.
9
Q
Simple partial seizure
A
- With this type, there are often motor signs in a single extremity or on one side of the body.
- However, focal onset seizure activity may spread to become generalized, making it difficult to distinguish from a generalized seizure.
10
Q
Complex partial seizure
A
- This type of seizure can occur at any age.
- Altered level of consciousness is one of the hallmark features.
- Complex partial seizures may include blank stare, lip-smacking, drooling, gurgling, as well as nausea and vomiting.
- Automatisms are quasi-purposeful motor or verbal behaviors that are repeated inappropriately and commonly accompany complex partial seizures.
- Complex partial seizures often last 30 seconds to 2 minutes and are associated with a post-ictal phase of confusion, sleep, or headache.
- Secondary generalization can occur in up to one third of children, so it is important to question witnesses about initial features to help differentiate a complex partial seizure from a generalized seizure
11
Q
Childhood absence epilepsy (petit mal seizures)
A
- This disorder typically starts around age 3 years.
- Absence seizures are characterized by loss of environmental awareness (“staring off into space”) and automatisms (e.g., eye-fluttering or lip-smacking).
- While these are generalized seizures, children usually regain their consciousness more quickly than the post-ictal phase seen in a generalized tonic-clonic seizure.
- Absence seizures are not associated with loss of tone or urinary continence.
- Absence seizures can be precipitated by hyperventilation or photic stimulation.
12
Q
Heredity and Febrile Seizures
A
Family and twin studies provide evidence that febrile seizures are hereditary, but the exact mode of inheritance is still unclear.
13
Q
most common cause of serious bacterial illness (SBI) in children.
A
UTI; Girls have a two- to fourfold higher prevalence of UTI than circumcised boys.
14
Q
Roseola infantum (also known as exanthem subitum, or sixth disease)
A
- common febrile rash illness of infants and young children under 2 years of age.
- Human herpesvirus-6 (HHV-6) is an important etiologic agent of roseola. About 30 percent of children with primary HHV-6 infection will develop roseola
15
Q
Hallmarks of roseola include:
A
- -A high fever (38.5 to 40.5 C) for 3-5 days in a typically fairly well-appearing child, followed by abrupt resolution of fever and development of a maculopapular rash
- -During the period of fever, some children have rhinorrhea.
- -A bulging fontanelle. This is an unusual physical finding in roseola and may lead to evaluation for meningitis.
