Fits + Funny Turns Flashcards
Causes of Confusion in Kids?
- Infx – meningitis, encephalitis (herpes) – cover both by giving aciclovir
o Pyrexia on its own can be a cause
o Hypoglycaemia
o Drugs/ETOH
o Hyxpoaemia
o Hyponatraemia
C/I to LP?
o Focal neurology
o Prolonged fit / focal fit
o GCS <13
o Coagulation disorder
o Abnormal pupils
Causes of Altered consciousness in kids?
Can be split into intracranial and systemic
Intracranial
Trauma – see head injury notes, ?NAI CNS infection Hypoxic ischaemia Space-occupying lesion – tumour, abscess, bleed Vascular malformation
Systemic
Metabolic e.g. glucose Sepsis Epilepsy Intoxication (tox screen of urine)Psychiatric – non-epileptic attacks disorder etc.
What are reflex anoxic seizures? What are they triggered by?
paroxysmal, spontaneously-reversing non-epileptic seizures caused by a reflex asystole resulting from ↑ vagal responsiveness
Triggered by pain, fear or anxiety
What age group get reflex anoxic seizures?
Peak between 6 months to 2yrs, but can occur at any age
Clinical features of reflex anoxic seizures?
- Child suddenly becomes pale and limp, will fall from standing, and loses consciousness
· This is followed by stiffening and clonic jerking of the limbs
· There may be upward eye deviation and urinary incontinence
· There is not tongue-biting (useful differential w/ epilepsy)
· Episodes are usually brief (30-60 seconds)
· Recovery is rapid but the child may feel tired and washed-out for some time
What investigations would you do in reflex anoxic seizures?
Often diagnosed on clinical findings alone but may be indicated if concerns about cause
· EEG – usually normal
· ECG – rule out long QT, pre-excitation, heart block and ventricular hypertrophy
· Vagal excitation tests (done under continuous EEG and ECG monitoring) – e.g. ocular compression inducing the oculo-cardiac reflex, rarely needed for Δ
Management of reflex anoxic seizures?
Drug Rx rarely, if ever, indicated
· Advise parents to place child in recovery position, avoid urge to pick child up
· Pacemaker – very rarely indicated, but can be effective
· Valproate and carbamazepine have been shown to abolish seizure but do not influence the frequency of attacks
Child will grow out of them, may recur in later life
What is a breath holding spell?
- Reflexive, involuntary acts in which a child stops breathing (not on purpose) for a short period, during which there may be a loss of consciousness and a change in tone
· Are typically precipitated by an upsetting/frightening event, or a painful experience
What age group get BHS?
Onset is before 2yrs in 90% of cases but tend to peak at 2 yrs.
· Are rare past 5yrs, but may persist until 8yrs
Aeitology of BHS?
Some attacks seem to result from hyperactive normal reflexes e.g.
o ↓ HR when eyes are rubbed
o Valsalva response when child tries to breathe/scream against closed glottis
· Some may be due hyperactivity in protective responses that normally only activate when O2 levels fall
how are BHS classified?
Cyanotic BHS
- Is the more common form
- Typically follows a tantrum or other upsetting event
- Skin turns BLUE shortly afterward (suggesting decreased O2)
Pallid BHS
- Is the rare form
- Typically follows a painful experience or being startled
- Skin becomes PALE (suggesting decreased blood flow)
Clinical Features of a BHS?
Characteristic sequence
o Inciting stimulus
o A cry
o Stops breathing
o Facial colour change
o Goes limp, unresponsive
o Seizure including jerking, sometimes incontinence
o Episode last less than a minute
Management of BHS?
Reassurance and recognition that episodes are not in the child’s control. A few children have significant Fe-deficient anaemia which limits O2-carrying capacity. This can be treated with Fe-supplement
Cyanotic BHS
o Cold rag on the child’s face at the start of the episode may stop progression
o Distraction or avoiding situations which lead to tantrums is the best ways of preventing these spells. Parents should avoid reinforcing initiating behaviour
Pallid BHS
o If slowed heartbeat confirmed, scopolamine can ‘unblock’ slow HR
What is a febrile convulsion?
Seizure accompanied by a fever, in the absence of intracranial infx (meningitis, encephalitis)
What age group get febrile convulsions?
Occur between 6 months – 5yrs (unusual for first seizure to be @ 5yrs). Peak at 9-20 months
Aeitiology of febrile convulsions?
Usually occur in a viral infx when there is a rapid rise in temperature (when it spikes)
· Commonly URTI
· Can occasionally occur with more serious infx e.g. meningitis – be vigilant for red flags
What are the 2 types of febrile convulsions?
Simple febrile convulsions
o Do not cause brain damage or ↓ intellectual performance
o 1-2% risk of developing epilepsy (same as general population)
Complex febrile convulsions
o Are focal, prolonged or repeated in the same illness
o 4-12% risk of developing epilepsy
What are risk factors for further seizures after a febrile convulsion?
30 – 40% have further seizures. This is more likely:
o Younger the child is when he/she has first seizure
o Lower the temperature at which the seizure occurred
o +ve FHx of febrile convulsions
Clinical features of febrile convulsions?
Usually occur early in a viral infx (e.g. UTI, URTI etc.)
· Brief (seconds - few minutes) generalised tonic-clonic seizure. There is loss of consciousness
· Post-ictal state – may want to sleep afterwards but wakes up back to normal
management of febrile convulsions?
Usually stop on their own
· Little that can be done to prevent them
· Rx underlying cause e.g. ABx for UTI etc.
· Concentrate on first aid and counselling parents:
o Reassure and inform parents
§ Advice sheets
§ Antipyretics do not prevent seizures
§ Tepid sponging is no longer recommended
o First-aid management of seizure
§ Note time started
§ Recovery position and keep objects away from mouth
§ Call 999 if seizure last for > 5 min à diazepam PR or buccal midazolam
o Signs to seek help
§ Meningitis signs: non-blanching rash, neck stiffness etc.
§ Dehydration
§ Altered consciousness/alertness
§ Fever > 5 days
§ Incomplete recovery within 1 hr
· Can get febrile status epilepticus – medical emergency. Treat as status epilepticus
