A Childs first seizure

Question 1

unfunny facts:

Answer 1

• theyre common
• 4-6% will have a seizure by 16
• transient, involuntary event caused by abnormal rhythms discharges from a group of neurons in the brain
• characterized by alterations of consciousness, behavior, motor skills, or sensation

Question 2

most common cause of seizures in kids:

Answer 2

fever

Question 3

seizure causes in kids:

Answer 3

fever

• idiopathic
• congenital malformation
• metabolic abnormalities
• infections
• trauma
• vascular event
• tumor
• drugs/poison

Question 4

what to do if theres a seizure:

Answer 4

• walk, don’t run, look at you watch
• assess ABCs
• place patient on side
• O2, O2 sat, monitor, IV access, bedside glucose
• intervene medically if needed for seizure if >3 min

Question 5

pre-seizure focused history:

Answer 5

• well prior to event?
• hx of seizures
• hx of fever/ recent infections
• recent antibiotics
• recent trauma
• adult Rx medications, toxic ingestions

Question 6

seizure focused hx:

Answer 6

• eye deviation, blank stare, drooling, cyanosis, incontinence
• generalized vs focal
• duration
• responsive or responsive

Question 7

post-seizure focused hx:

Answer 7

• single or multiple
• mental status after event
• EMS observations at time of arrival

Question 8

PMH to find out for seizures:

Answer 8

Neurosurgical procedures (VPS)
Prematurity, developmental delay
History of meningitis, CNS infections
History of head trauma
Hypercoagulable states (sickle cell disease)
Immunosuppression

Question 9

social hx seizures:

Answer 9

Toxic exposures
Adult Rx medications in the home
TB exposures/access to INH
Formula mixing

Question 10

physical exam post seizure:

Answer 10

Vital signs (rectal temp)
General appearance and mental status
Focused exam
Focal neurologic deficits
Signs of increased ICP (bulging fontanelle, papilledema)
Skin lesions (Ashleaf spots, shagreen patch, café au lait)
Nuchal rigidity
Poor perfusion
Altered motor tone
Prolonged post-ictal lethargy
Generalized petechiae

Question 11

categorize the seizure:

Answer 11

Febrile seizure
Seizure with epilepsy syndrome
Seizure without epilepsy syndrome

Question 12

Criteria for febrile seizure:

Answer 12

Seizure associated with fever > 100.4 (most have temp > 102)
Child less than 6 years
No signs of CNS infection, no meningeal signs
No acute metabolic abnormality
No history of prior afebrile seizures

Question 13

febrile seizure facts:

Answer 13

• 2-5% of kids less than 5
• 6 months to 6 years
• peak 12-18 months
• majority on first day of illness
• often first indication child is sick

Question 14

predisposing febrile seizure factors:

Answer 14

• viral or bacterial infections
• after DTP or MMR vaccine
• familial

Question 15

simple febrile seizures:

Answer 15

• less than 15 min
• generalized
• no focal features
• does not recur within 24 hrs

Question 16

complex febrile seizures:

Answer 16

• last more than 15 min
• focal features or postical paresis (Todd’s paralysis)
• recurrence within 24 hrs

Question 17

eval and management of febrile seizure:

Answer 17

• stabilize pt
• focused hx and physical
• categorize seizure
• determine probability of intracranial infection and acute bacterial meningitis
• determine need for diagnostic studies
• establish disposition

Question 18

Features that increase risk of ABM:

Answer 18

Illness > 3 days
Physician visit within last 48 hrs
Current antibiotics for extracranial infection
Immunocompromise
Unvaccinated child
Multiple seizures
Prolonged post-ictal phase

Question 19

New AAP guidelines 2011 for LP:

Answer 19

LP indicated in children with obvious meningeal signs
LP is AN OPTION in children 6-12 months
Deficient in Hib and S. pneumoniae immunizations
Pretreated with antibiotics

Question 20

ABM concerning exam findings:

Answer 20

Focal neurological deficits
Altered motor tone
Nuchal rigidity
Poor perfusion
Generalized petechiae

Question 21

Status and fever greater risk for…

Answer 21

meningitis

Question 22

disposition of simple febrile seizure:

Answer 22

-back to baseline and reassuring hx and physical can be discharged

Question 23

febrile seizure prognosis:

Answer 23

• 33% experience recurrent febrile seizure

- 2% risk of epilepsy

Question 24

Factors that increase recurrence risk:

Answer 24

Young age onset ( < 1 year)
Family history of febrile seizure
Baseline developmental delay
Complex febrile seizure

Question 25

Reduction in temperature with acetaminophen or ibuprofen reduces the risk of subsequent febrile seizures? (t/f)

Answer 25

false

Question 26

antipyretics use in febrile seizures:

Answer 26

Antipyretics recommended for patient comfort | Does not affect recurrence rate of febrile seizures

Question 27

preventative tx for febrile seizures:

Answer 27

Neither continuous or intermittent anticonvulsant therapy recommended for children with simple febrile seizures Risks and side effects of anticonvulsants outweigh the benefits of treating Rectal diazepam for prn use an option

Question 28

discharge instructions:

Answer 28

``` Give parents information about what to do Safe place Place child on his/her side Nothing in mouth Chin lift/jaw thrust When to call EMS ```

Question 29

indications for admission:

Answer 29

``` Prolonged postictal phase Complex febrile seizure Age < 6 months Social concerns Inability of caretakers to provide appropriate observation Prolonged distance to medical care ```

Question 30

Febrile Seizure Pearls

Answer 30

Majority are simple febrile seizures Laboratory evaluation and neuroimaging not indicated in simple febrile seizures Prophylactic anticonvulsants not recommended Parental education key 33% will have recurrence Approximately 2% will develop epilepsy

Question 31

infantile spasms epilepsy syndrome eval:

Answer 31

Need urgent EEG, MRI, and metabolic evaluation with neurology consultation Mortality as high as 15-20% Only 5-10% or children with infantile spasms have normal intelligence

Question 32

epilepsy syndrome tx:

Answer 32

Absence: ethosuximide, valproic acid, lamotrigine, levetiracetam JME: valproic acid, topiramate, levetiracetam BECTS: May not require therapy; outgrow by adulthood Can use same AEDs used to treat partial seizures Responsive to carbamazepine Infantile Spasms: ACTH, steroids, zonisamide, topiramate, vitamin B-6 Lennox-Gastaut Syndrome Often requires multiple medications

Question 33

non epilepsy sz tx?

Answer 33

Majority of children with first unprovoked seizure will have few or no recurrences ~10% will go on to have many seizures regardless of therapy Treatment with AED after a first seizure as opposed to after a second seizure has not been shown to improve prognosis for long-term seizure remission

Question 34

admission criteria for non epilepsy:

Answer 34

``` Age (< 6 months) Etiology of seizure Seizure control Social concerns Inability of caretakers to provide appropriate observation Prolonged distance to medical care ```

Question 35

pearls:

Answer 35

Seizures in children are common Most first time seizures in children are febrile seizures Evaluate the fever, not the seizure LP not indicated in well appearing, immunized children who present with a simple febrile seizure Most children with a non-febrile seizure will require an EEG and neuroimaging but rarely needed emergently Exception is infantile spasms No benefit in initiating anticonvulsant therapy after first seizure as opposed to second seizure

Question 36

most common cause of neonate sz?

Answer 36

HIE

Question 37

neonate sz tx?

Answer 37

phenobarbital