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Adv Prac Child Adolescent 6036 Test 1 COMPLETE ☑️ > Module 2 (a) Pediatric Neurology - Seizures > Flashcards

Module 2 (a) Pediatric Neurology - Seizures Flashcards

1
Q

Seizure Definition

A
  1. Transient occurrence of signs and/or symptoms due to an abnormal excessive or synchronous neuronal activity in the brain
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2
Q

Epilepsy Definition

A
  1. At least 2 unprovoked seizures occurring more than 24 hours apart
  2. One unprovoked seizure and a probability of further seizures
  3. Diagnosis of epilepsy syndrome
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3
Q

EEG Info

A
  1. Recording of electrical activity along the scalp produced by the firing of neurons in the brain
  2. EEG alone CANNOT make or refute a diagnosis of epilepsy
  3. Sleep deprivation preferred
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4
Q

Definitions of Seizure Activity

A
  1. Tonic — Sudden tension of skeletal muscles
  2. Clonic — Rapid contraction and relaxation of muscles (Convulsions)
  3. Myoclonic — Brief involuntary twitching of a muscle or muscle group
  4. Atomic — Sudden loss of tone (Drop Seizures)
  5. Ictal — During the event
  6. Interictal — Between events
  7. Postictal — After the event
  8. Automatisms — Set of brief, unconscious behaviors
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5
Q

Most Common Seizures?

A
  1. Focal seizures are most common type of seizure

- Most common focal seizure is a Focal seizure w/out impaired awareness

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6
Q

Etiology of Seizures

A
  1. Genetic
  2. Structural — Physical problem in the brain.
    - Congenital Ex: Cortical displasia or tubular sclerosis
    - Acquired Ex: Scar tissue from a stroke or trauma
  3. Metabolic — Ex: Glucose transport deficiency (Mitochondrial disorders)
  4. Immune — Inflammation resulting in seizures. Ex: Encephalitis
  5. Infectious — CNS infection Ex: HIV
  6. Unknown — MOST COMMON TYPE
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7
Q

Seizure Prognosis and Outcomes

A
  1. Remission of seizures w/ Medication management is 70% in childrenTEST — 30% of seizures are refractory to medication
  2. 50% of seizures are limited to childhood
  3. Goals of care
    - Decrease seizure frequency as much as possible
    - Improve quality of life
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8
Q

Risks for Intractable Seizures

A
  1. Continued seizures while on medication
  2. Family medical hx of epilepsy
  3. Symptomatic epilepsy - Ex: Stroke that left damage
  4. Low IQ
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9
Q

Key Components of Seizure Hx.

A
  1. Birth Hx — Hypoxia or trauma?
  2. Hx of CNS infection or TBI?
  3. Fam hx of epilepsy
  4. HPI — Focus on context
    - Sleep deprivation
    - stress
    - Menstrual cycle
    - Infection/illness
    - Patients w/ epilepsy — Missed doses of AED
  5. Seizure Description — Take video if possible
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10
Q

Types of Seizures

A
  1. Generalized — Motor and Non-motor
    - Both sides of the brain (Both hemispheres) are impacted **TEST
    - Motor Example — Ex: General Tonic-Clonic
    - Non-Motor — Ex: Absence seizure
  2. Focal Seizures (Partial) — Motor and Non-motor
    - Aware (simple)
    - Impaired Awareness (Complex)
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11
Q

Generalized Seizures

-Info

A
  1. Bilateral at onset — BOTH hemispheres are impacted
    - Bilateral motor manifestations
    - Bilateral EEG changes
  2. Can be motor or non-motor
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12
Q

Focal Seizures

-Consciousness Maintained

A
  1. Motor — Jerking movements of one part of the body, tonic movements (“Fencing posture”)
  2. Aura — Focal seizure w/ sensory or psychic symptoms
  3. Automatic — Changes in BP, HR, bowel function, etc.

—Temporal Lobe epilepsy is the MOST COMMON type of focal Epilepsy’s**
-Starts with a seizure aura — Considered part of the seizure

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13
Q

Focal Seizures

-Alteration of Awareness

A
  1. Behavioral arrest lasting 30-120 seconds
    - Stare into space
    - Automatisms are common
    - Unaware and unresponsive
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14
Q

Epilepsy Syndromes

-Definition

A
  1. Distinct clinical entity defined as a complex of clinical features, signs and symptoms that together define a distinctive recognizable clinical disorder.
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15
Q

Epilepsy Syndromes

-Types encountered in Primary Care?

A
  1. benign focal epilepsies of childhood
  2. Childhood absence epilepsy
  3. Juvenile myoclonic epilepsy
  4. Infantile spasms
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16
Q

Benign Focal Epilepsies of Childhood

-Common Types?

A
  1. Limited to childhood
  2. Occur in developmentally and neurologically typical children
  3. Most common types:
    - Benign epilepsy w/ centrotemporal spikes (BECTS) — Also known as benign Rolandic epilepsy (BRE)
    - Benign occipital epilepsy
    - Panayiotopolous syndrome
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17
Q

Benign Focal Epilepsies of Childhood

-Benign Epilepsy w/ Centrotemporal Spikes (BECTS)

A
  1. 10-20% of all childhood epilepsies
  2. Family hx of epilepsy is fairly common
  3. School-age children w/ normal development
  4. Most seizures occur at night/ upon awakening
    —Often in the face — Twitching, numbness/tingling, drooling, difficulty speaking
  5. EXCELLENT prognosis w/ infrequent seizures and LOW risk for status epilepticus
  6. Antiepilépticos drugs often NOT recommended
    - If meds are used, consider weaning after 1 year seizure free
  7. May be associated w/ mild cognitive impairment
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18
Q

Benign Focal Epilepsies of Childhood

-Benign Occipital Epilepsies 2 Types

A
  1. Benign occipital epilepsy of childhood
  2. Panayiotopoulos syndrome

-Can have features of both types
-Characteristic EEG findings
—Occipital spikes

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19
Q

Benign Focal Epilepsies of Childhood
-Benign Occipital Epilepsy
(Panayiotopoulos Syndrome)

A
  1. Occurs in YOUNGER children (<5 yrs old w/ range of 1-14 yrs)
  2. Seizure Sx’s include
    —Vomiting, syncope, and prominent autonomic Sx’s (Pallor, miosis, incontinence, coughing, hyper-salivation, tachycardia

—Typically nocturnal and last longer than 5 minutes
—1/3 to 1/2 last longer than 30 minutes ** This would be STATUS Epilepticus

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20
Q

Benign Focal Epilepsies of Childhood

-Benign Occipital Epilepsy of Childhood

A
  1. Mean age at onset is 8-9 years
  2. Seizure characteristics
    —Visual Sx’s (Blindness, visual hallucination)
    —May also have hemiclonic activity, automatisms, migraine-like headache, versive movements
    —Shorter duration — < 5 minutes
  3. Typically occur during the day*
21
Q

Absence Epilepsy

A
  1. GENERALIZED seizures**
  2. Sudden, profound impairment of consciousness w/out loss of body tone
  3. Duration approximately 10 seconds
  4. High frequency — (10+/day)
  5. May be subtle
  6. Characteristic EEG finding
22
Q

Absence Epilepsy 1st line Tx?

A
  1. Ethosuxamide (Zarontin) — FIRST LINE TX
23
Q

Childhood Absence Epilepsy

A
  1. Onset between 4-10 yrs
  2. Put to 20% have hx of febrile seizures
  3. Almost 50% have a first or second decree relative w/ seizures
  4. Increased Risk for GTCS
  5. High incidence of psychiatric comorbidities — ADHD, Anxiety
24
Q

Juvenile Absence Epilepsy

A
  1. Less common than childhood onset
  2. Peak age of onset 10-12 years
  3. Seizures are typically longer and more severe impairment in consciousness
  4. Usually a life long disorder
25
Q

Juvenile Myoclonic Epilepsy

A
  1. Most diagnosed between age 12-18 yrs And otherwise healthy kids
  2. About 50% have FMH of generalized seizures
  3. Get good hx of presence of other seizure types like absence seizures
  4. LIFE LONG disorder
  5. At risk for cognitive, behavioral, and social difficulties
  6. Increased risk for anxiety, mood disorder, and personality disorder
  7. Overall favorable prognosis
26
Q

Juvenile Myoclonic Epilepsy

-Treatment

A
  1. Valproate is FIRST LINE treatment
  2. Lifestyle
    - Sleep
    - Alcohol/drug consumption
    - Medication non-adherence
27
Q

Infantile Seizures

A
  1. 90% onset < 1 year old
  2. Developmental regression after onset
  3. Initial seizures infrequent and isolated — Eventually frequent and occur in clusters
  4. Hypsarrhythmia on EEG
28
Q

Infantile Spasms

-Seizure Description

A
  1. Sudden, BRIEF contractions of >/= 1 muscle group (neck, trunks, extremities) followed by a longer, less intense tonic phase
  2. Can be flexor, extensor, or mixed flexor-extensor
  3. Typically symmetric and synchronous
  4. Can occur in clusters lasting several minutes
  5. Most frequent just after WAKING , and almost exclusively occur in the DAYTIME
  6. May be followed by motor arrest or decreased responsiveness
29
Q

Infantile Spasms

-Prognosis

A
  1. POOR prognosis and early recognition is critical
  2. Differential diagnosis
    - GERD
    - Exaggerated/hyperactive reflexes
    - Benign myoclonus of infancy
    - Shuddering attacks
    - Benign paroxysmal torticollis
30
Q

Seizures and Fever

A
  1. Often a child’s first seizure will occur in the setting of fever
  2. Three possibilities
    - Nervous system infection
    - Underlying seizure disorder
    - Febrile Seizure
31
Q

Febrile Seizures

A
  1. 2-4% of children <5 yrs
  2. Diagnostic Criteria
    - Seizure w/ temp >100.4
    - No CNS infection/inflammation
    - Absence of acute systemic metabolic abnormality that may produce convulsions
    - No Hx of previous febrile seizures
32
Q

Febrile Seizures

-Risks

A
  1. High fever
  2. Viral infection
  3. Recent immunization — DTP, MMR, MMR-V
  4. FMH febrile seizures

Other Risks

  • Prenatal exposure to nicotine
  • Iron insufficiency
  • Allergic rhinitis/Atopic disease

MAXIMUM Height of fever is greatest contributing risk

33
Q

Febrile Seizures

-Simple Vs Complex

A
  1. Simple
    - Generalized, Duration <10-15 minutes, No recurrence w/in 24 hrs
  2. Complex
    - Focal onset, Duration >15 minutes and >1 in 24 hrs
    - Febrile status epilepticus - Duration >30 minutes
34
Q

Febrile Seizures

-Diagnostic Criteria

A
  1. MUST r/o CNS infection and underlying structural abnormality
    - Altered LOC
    - Meningismus
    - Petechiae
    - Tense or bulging fontanelle
    - Focal differences in muscle tone, strength or movements
    - Post-I tal drowsiness > 10 minutes
35
Q

Febrile Seizures

-Work up & Education

A
  1. No work up necessary if — Simple febrile seizure and NORMAL neurological exam
  2. Education
    - Role of antipyretics
    - Risk for recurrence of febril seizures
    - Risk for subsequent epilepsy
  3. Provide at-home benzodiazepine for seizure >5 minutes
36
Q

Status Epilepticus

-Definition

A
  1. Single seizure lasting >30 minutes OR a cluster of seizures w/out return to baseline lasting >30 minutes
  2. Duration >5 minutes should be treated as Status Epilepticus
37
Q

Status Epilepticus

-Rescue Meds

A
  1. Rectal Diazepam

2. Bucal or intranasal Midazolam

38
Q

Non-Pharmacologic Treatment of Seizures/Epilepsy

A
  1. Educate on Seizure Precautions
    - Lifestyle habits
    - Avoiding head injury
    - Water safety
    - Emergency seizure plan
  2. Assess for/Treat anxiety and mood disorders
  3. Address cognitive issues
  4. Make sure they have a neurology provider
  5. Adolescents
    - Alcohol avoidance
    - Transition to adulthood
    - Driving and Sex (Some Seizure meds can interfere with birth control and they are teratogenic)
39
Q

Anti-Epileptic Drugs (AED)

A
  1. First-time unprovoked seizure
    —Typically NOT treated with AED
    —Tx withheld until a pattern of recurrence is established — AED’s used w/ remote symptomatic etiology and focal seizure w/ abnormal EEG
  2. Second unprovoked seizure
    —Typically started on AED
    —Exception: Infrequent and/or “mild” seizures
40
Q

Antiepilépticos Drug Goals

A
  1. Goals include:
    - Minimal seizures
    - Maximal Quality of life
    - Few S/E
  2. General Principles
    - Low and slow
    - Monotherapy preferred
    - High index of suspicion for AE’s
41
Q

AED: Implications for Primary Care?

A
  1. Bone health
    - Screen for Vit D deficiency and use supplemental calcium and vit D
  2. Psychiatric/behavioral health screening
    - Depression
    - SUICIDALITY
    - ADHD
    - Learning issues
  3. Adherence to AED
42
Q

AED’s

-Potential Serious/Life Threatening Reactions?

A
  1. Stevens-Johnson Syndrome SJS and Toxic epidermal necropsy is (TEN)
  2. Drug reaction w/ eosinophilia and systemic Sx’s (DRESS)
  3. AED + RASH = STOP IMMEDIATELY
43
Q

Stopping AED Therapy

A
  1. Children: Consider w/drawal after 2 years w/out seizures — Always SLOW taper over several weeks to a few months
  2. Risk for return of seizures:
    - Motor or cognitive deficit
    - Abnormal EEG at time of DC
    - Symptomatic epilepsy
    - Stopping AED before 2 yrs seizure free
  3. ALWAYS Taper the AEDs
44
Q

Adolescent Females on AEDs

A
  1. ALL on AED require FOLIC ACID supplementation
    - Valproate or carbamazepine = 4mg/day
    - All other AEDs = 0.4 - 0.8 mg/day
  2. Decreased efficacy of ALL hormonal contraceptives
    - Use at least 50 mcg of estrogen
    - Long-acting reversible contraception recommended **
  3. “Morning-After Pill” also affected by AED
    - Two doses of levonorgestrel 1.5 mg separated by 12 hrs is recommended
45
Q

Adolescent Females on AEDs

-Pregnancy

A
  1. > 90% of women w/ epilepsy have good outcomes
  2. May need AED DC’d or dose adjusted during pregnancy — Under guidance of neurology
  3. Seizures (Especially GTCS) thought to be harmful to fetus**
46
Q

AED’s that are Teratogenic

A
  1. Congenital Malformations
    - Phenobarbital
    - Phenytoin
    - Valproate
    - Topiramate
    - Carbamazepine
  2. Neuro-cognitive Effects/Autism
    - Valproate
    - Phenytoin
    - Carbamazepine
    - Phenobarbital
47
Q

Syncope Vs Seizures

A

Syncope is the biggest differential w/ seizures

  1. Sudden, brief LOC w/ loss of postural tone w/ spontaneous recovery
  2. In children and adolescents, almost always benign
  3. WORRY IF
    - Occurs during or after athletic event
    - Cardiac risk factors
    - Concurrent eating disorder
  4. Seizures typically last longer and include prolonged tonic-clonic activity and/or post-ictal phase
48
Q

Syncope Causes?

A
  1. Vaso-Vagal Syncope —Precipitating event + Prodrome
  2. Orthostatic Hypotension — Syncope that occurs w/ postural change
  3. Toxic Exposure — Secondary to decreased cardiac output or sudden LOC
  4. Hypoglycemia — Preceded by hunger, weakness, diaphoresis
49
Q

Breath Holding Spells

A
  1. Onset age 6-24 months; resolves by 5 years
  2. Triggered by emotional insult — Pain, anger, fear
  3. Can have associated brief posturing or tonic clonic motor activity
  4. May be associated w/ IRON DEFICIENCY — Check serum ferritin and a CBC

Adv Prac Child Adolescent 6036 Test 1 COMPLETE ☑️ (5 decks)

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