Fits, faints and funny turns

Question 1

Causes in infants and toddlers (6)

Answer 1

Apnoea and acute life threatening event
Febrile convulsions
Breath-holding (cyanotic)
Reflex anoxic spells
Infantile spas,s
Hypoglycemia and other metabolic

Question 2

In what age group does cyanotic breath holding usually occur

Answer 2

Older babies and toddlers

Usually resolves by 18 months

Question 3

Presentation in breath-holding (cyanotic)

Answer 3

Precipitated by crying->hold breath, becomes cyanotic, becomes limp, breathes, then conscious again. No post-ictal phase.
Parents need to be reassured

Question 4

Pallid spells->what are they, age, presentation, advice to parents

Answer 4

6 months to 2 years.
Head injury->vagal response->bradyC and collapse, become pale and fall. May have eye rolling, iincontinence, tonic contractions, but no tongue biting. When they arouse after 30-60 seconds, may be tired and emotional.

Advice to parents is these are benign, usually resolve before school age, no long term consequences, no evidence of behavioural issues.

Question 5

When does infantile spasm present, characteristics, EEF, association, treatment

Answer 5

Onset in infancy, peaks at 4-8 months.
Myoclonic epilepsy->flexion of neck and upper limbs, can occur in clusters lasting up to half an hour, jacknife spasms
Associated with developmental regression. May have history of perinatal meningitis or asphyxia.

Question 6

What features may suggest an underlying metabolic disorder

Answer 6

Developmental delay
Dysmorphism
Hepatosplenomegaly
Micro/macro-cephaly

Question 7

Causes in school aged children (4)

Answer 7

Epilepsy
Syncope
Hyperventilation
Arrythmia

Question 8

Important history

Answer 8

Description of the event
What the child was doing at the time
Precipitating events
ALOC
Involuntary movements, tongue biting, loss of continence
Change in colour (pallor/cyanosis)
How did the child react following, was there a post-ictal phase
If recurrent->parents should aim to record the episode
Developmental history (infantile seizures, metabolic conditions)
Family history-> developmental problems, febrile seizures, cardiac arrythmias.

Question 9

Important physical examination

Answer 9

Rarely helpful in between episodes
Neurological
Cardiovascular
Dysmorphic features.

Question 10

When would you consider investigations rather than clinical diagnosis

Answer 10

If considering apnea, epilepsy, metabolic conditions.

Question 11

Investigations and interpretation

Answer 11

EEG->Hypsarrythmia in infantile spasm, 3 per second spike and wave in absence seizures, epileptiform may be seen in epilepsy
ECG->rhythm, PR, QT
24 h ECG-> if arrythmia is suspected of causing syncope
Blood chemistry->hypoglycemia, but unhelpful between episodes.
pH monitoring->apnea in infants may be due to GOR

Question 12

Generalised seizure types

Answer 12

Tonic-clonic epilepsy
Absence
Infantile spasms

Question 13

Focal seizure types

Answer 13

Temporal lobe seizures

Question 14

Forms of epilepsy

Answer 14

Tonic clonic
Simple absence
Complex partial
Myoclonic

Question 15

Presentation of complex partial

Answer 15

ALOC, strange sensations, semi-purposeful movements

May have post-ictal phase

Question 16

Presentation of tonic clonic

Answer 16

Tonic phase: suddent LOC, limbs extend, back arches, teeth clench, breathing stops, tongue may be bitten
Clonic: intermittent jerking movements, irregular breathing may urinate and salivate
Post-ictal->child is tired/sleepy

Question 17

Counselling parents about breath holding

Answer 17

Cause unknown->slowing of heart, change in breathing patterns. Associated with strong emotions, anger, fear, pain, frustration. Not harmful to child.
Can have blue or pale spells. Pale less common- following an injury. No treatment needed if child is able to recover by themselves.
`1. lay them on their side and watch them, remove objects
2. Your child will start to breathe on their own.
3. Do not put anything in their mouth, including your fingers.
4. Once recovered i-> Don’t punish or reward them or make a big fuss.
5. Not to ‘give in’ to your child to stop another attack from happening in the future.
6. Distraction may be a good way of avoiding a tantrum and a resulting breath holding spell

Question 18

When to see a doctor with breath-holding spell

Answer 18

Very frequent
Seizure > few minutes, then confused/drowsy
Becomes very pale/unconscious for no reason

Question 19

Common toxidrome presentations: cholinergic, anticholinergic, TCA

Answer 19

Cholinergic: (organophosphates) salivation, sweating, bronchospasm
Anticholinergic: dry flushed skin, mydriasis
Tricyclic antidepressants: seizures, wide QRS complex