Paeds - Suspected Seizure Flashcards
What are the steps for managing status epilepticus in a child
> 1-month old?
Step 1:
- Maintain airway + High-flow O2 + blood glucose
Step 2:
- IV access –> Lorazepam 0.1 mg/kg
- No IV –> Midazolam (buccal) 0.5 mg/kg OR Diazepam (rectal) 0.5 mg/kg
Step 3:
- IV Lorazepam 0.1 mg/kg + call for senior
Step 4:
- If on phenytoin –> prepare phenobarbitone
- If not on phenyotin –> prepare phenytoin
Step 5:
- Senior review to confirm epileptic seizure
- Seek anaesthetic / ICU advise
- If on phenytoin –> give phenobarbitone 20 mg/kg IV/IO over 20 mins
- If not on phenyotin –> prepare phenytoin 20 mg/kg IV/IO over 20 mins
Step 6:
- Anaesthetist
In a child with suspected seizure what questions do you want to ask the parents regarding ‘prior to the episode’?
- Behavioural change
- Health that day
- Time of episode
- Setting
- Activity at onset
- Warning: visual, hearing, fear, sweaty, light headedness
- Triggers
- Time of last meal - low blood glucose
In a child with suspected seizure what questions do you want to ask the parents regarding ‘during the episode’?
- Onset - sudden?
- Unresponsive vs aware
- Symmetrical vs asymmetrical movement?
- Facial movement
- Eye movements
- Posturing
- Clonic/myoclonic/spasm or tonic-clonic
- Breathing changes
- Incontinence
- Tounge biting
- Duration of seizure
In a child with suspected seizure what questions do you want to ask the parents regarding ‘after the episode’?
- Sleepy / disorientated
- Nausea / vomiting
- Amnesia of events
- Strange behaviour
- Weakness
- Time taken to recover
In a child with suspected seizure what questions do you want to ask the parents regarding ‘recent illness’?
- head injury/trauma
- fever
- diarrhoea
- weight loss
- headaches
- visual disturbances
- vomiting / nausea
- poor co-ordination
- weakness
- taken drug/substance
What are indications for urgent head MRI or CT in children?
- Encephalopathy or coma
- Suspected raised intracranial pressure
- Progressive neurological deficit
What are the indications for elective head MRI in a child?
- child < 2-year of age at onset
- hard focal neurological signs
- focal epilepsy
- significant learning difficulties
- an epilepsy resistant to full doses of 2 appropriate drugs
What are febrile convulsions?
Seizures provoked by fever in otherwise normal children
- Typical onset = 6 months - 5 years
- Seen in 3-5% of children
- Fever must be at least present in immediate post-acute period
- Prognosis:
- 1 in 3 have further febrile convulsions (depends on seizure risk factors)
- If further febrile convulsions –> teach parents how to use rectal diazepam or buccal midazolam
What is the link between febrile convulsions and epilepsy?
Majority of children who have febrile convulsions have no future issues, but a small proportion can develop epilepsy in later life!
- Risk factors for developing epilepsy:
- FHx of epilepsy
-
Complex febrile convulsions
- i.e. > 15 mins, focal not generalised, repeat episodes in < 24hrs)
- Background of neurodevelopmental disorder
- 0 risk factors = 2.5% risk of epilepsy
- all 3 risk factors = ~ 50% risk of epilepsy
If pt goes on to develop epilepsy it tend to …
- originate from one of the temporal lobes
- associated with atrophy + scarring (gliosis) - seen on MRI –> called ‘mesial temporal sclerosis’ (MTS) - seen in attached image (high signal in R hippocampus + R atrophy = MTS)
What are the features of febrile convulsions?
Features:
- Viral infection causing fever
- Seizure is brief ( < 5 mins) - if > 5 mins phone an abulence
- 15-30 mins = complex febrile convulsion
- Most commonly tonic-clonic seizure
- Typically no recurrence within 24hrs
- Recover in < 1 hour
- Boys > girls
What are the types and features of febrile convulsions?
Simple febrile convulsions:
- < 15 mins
- Generalised seizure
- Often no recurrence within 24hrs
- Often complete recovery in < 1hr
- Don’t admit unless < 18-months or suspect other cause
Complex febrile convulsions:
- 15-30 mins
- Focal seizure (can be generalised)
- May have repeat seizures within 24hrs
- Post-ictal neurological abnormalities (most frequently a Todd’s palsy/paralysis - focal motor weakness, persists for up to 24hrs)
- Admit for observation
Febrile status epilepticus:
- > 30 mins
- Admit for close observation
EEG’s are not suggested for abfrebile seizures!
But what are some indications for urgent EEG?
- Suspected non-convulsive status
- Non traumatic encephalopathy
- Coma of unknown cause
Elective EEG:
- Strong suspicion of epilepsy (to support classification)
- developmental or language regression
What epilepsy questions might you have for a patient in A&E presenting with collapse with TLOC?
-
Previously well / any illness before event?
- illness can trigger seizures in those with epilepsy e.g. infection, dehydration, sleep deprivation, drug use
-
What was happening at the time of the TLOC?
- Precipitant? standing / istting / lying / on standing upright
- TLOC triggered by postural change is likely vasovagal
-
Any warnings prior to event?
- Pre-syncope symptoms = light-headedness, nausea, sweating and ‘greying’ out of vision
- Epileptic seizure = unexplained smell, deja-vu, focal muscle jerking/twitching
-
First memory on waking up?
- Syncopal blackout = pt regains awareness / memory quickly
- Epileptic seizure = foggy or no memory before paramedics turn up / arriving in hospital
-
Any injuries, tongue biting, urinary / faecal incontinence?
- If yes to above –> more likely an epileptic seizure
- Beware! urinary incontinence can occur in syncope (especially women)
- Any previous similar episodes?
What epilepsy questions might you have for an observer of a patient in A&E presenting with collapse with TLOC?
-
Any warning signs beforehand?
- focal onset seizure = focal twitching, a forced head turn, eye deviation or blank ‘staring’
- syncope = look pale, sweaty, complain of nausea / light-headedness
-
Did they fall stiffly or floppily?
- floppy = likely syncope
- stiffly = generlaised seizure (tonic phase)
-
Did they shake + what did it look like?
- generalised seizure = rigid (tonic) phase + rhythmic clonic jerks afterwards, ↓ in amplitude + frequency
- syncope = a few brief myoclonic jerks, low amplitude + less rythmic
-
Cyanosis?
- generalised seizure = blue lips (tonic-clonic involuntary muscle contraction prevents normal breathing)
-
Duration of LOC?
- syncope = < 1 min
- generalised seizure = 1-5 mins
-
Duration of shaking?
- generalised seizures = < 5 mins
- prolonged shaking = status epilepticus or NEAD
-
How long did it take to recover afterwards?
- syncope = speedy (few mins)
- seizure = drowsy for 15 mins
- prolonged unresponsiveness can be ‘pseudosleep’ of NEAD
How is a seizure managed actuely?
- Airway: check + maintain airway - apply O2 if appropriate
- Position: recovery position
-
Medication: benzodiazepines (if seizure is prolonged)
- Rectal diazepam 10-20 mg for adult (repeat once after 10-15 mins if needed)
- Midazolam oromucosal solution 10mg adult
What investigations would you do after an acute seizure?
Beside:
- Full neurological exam
- Cardiac exam
- Vital obs:
- Temp, HR, BP, SpO2
Blood:
- Blood glucose
- FBC - infection
- U+Es - hyponatraemia, hypocalcaemia
Other:
- ECG
- CT - if abnormal neurological findings or prolonged ↓ conciousness
A pt has a focal seizure of one of their temporal lobes - what symptoms might they experience?
HEAD mneumonic:
- Hallucination (auditory/gustatory/olfactory)
- Epigastric rising sensation / Emotional (e.g. fear)
- Automatisms (see below)
- Deja vu (memory disturbance) / Dysphasia post-ictal
Other symptoms:
- Fear
- Bizarre psychotic phenomena e.g. derealisation and depersonalisation or elation
- Automatisms (absent mindedly doing a simple action) e.g. plucking at clothes, lip-smacking, repetitive mumbling, repetition of a stereotypical phrase
- Impaired awareness - during/after in the case of ‘complex’ partial seizure
Besides the PC / HPC - what other specific
questions are useful in a seizure history?
- Significant head injuries
- Hx of CNS infection - meningitis, encephalitis, cerebral abscess
- FHx of epilepsy
-
Birth history:
- prematurity, difficulty delivery e.g. forceps, postnatal issues e.g. hypoxia or jaundice
- seizures in childhood / infancy
- Medications - some can lower seizure threshold e.g. antipsychotics (worse with atypicals), quinolone Abx (ciprofloxacin or levofloxacin), antidepressants e.g. amitriptyline and some painkillers e.g. tramadol
- Illicit drug use / alcohol use
Name factors which can ↑ an epileptic pt’s liklihood of having a seizure.
- Illness e.g. LRTI or UTI
- Poor concordance with AED medication
-
New medication interaction - some can lower seizure threshold e.g.
- antipsychotics (worse with atypicals)
- quinolone Abx (ciprofloxacin or levofloxacin)
- antidepressants e.g. amitriptyline
- some painkillers e.g. tramadol
- Alcohol excess
- Metabolic disturbances e.g. hypo-/hyper-natraemia, hypoglycaemia, hypocalcaemia (↓ Ca)
- Disturbed sleep, jetlag, fatigue
- GI disturbances which cause poor AED absorption
What guidance might parents of a child who has experienced a febrile seizure / or any seizure need?
- Counselling on recurrence risk of febrile seizure / seizures + risk of epilepsy
- 1st aid training on what to do / not to do e.g. don’t put anything in child’s mouth or do chest compressions)
- Consider training to administer rescue meds e.g. buccal midazolam at 5 mins
- Educate on when to call an ambulance e.g. after 5 mins of a convulsive seizure or if rescue meds were ineffective after 5 mins
- Follow up appointments by either a Consultant or refer to epilepsy specialist
Before what age is a child having a hand preference considered abnormal?
What is early hand preference associated with?
Hand preference before 12-months old is abnormal
Early hand preference is associated with:
- Higher risk of hemiplegia of non-dominant side
- Associated with cerebral palsy
What are the major developmental milestones for
Social Behaviour and Play?
What are the major developmental milestones for
Speech and Hearing?
What are the major developmental milestones for
Gross Motor?
What are the major developmental milestones for
Fine Motor & Vision?
In a child what form of brain imaging is preferred?
MRI brain
- No radiation dose (CT is a lot of radiation for a child)
- Young children may need to be sedated or put under GA in order to be still enough for an MRI
- Only do CT brain when it is urgent and MRI is not available
What is Cerebral Palsy?
Cerebral palsy is a disorder of movement & posture
It is due to a non-progressive lesion of the motor pathways in the developing brain
- affects 2 in 1000 birth
- most common cause of major motor impairment
What causes Cerebral Palsy?
Antenatal (80%) causes:
- cerebral malformation
- congenital infection (e.g. rubella, toxoplasmosis, cytomegalovirus)
Intrapartum (10%):
- birth asphyxia / trauma
Postnatal (10%):
- intraventricular haemorrhage
- meningitis
- head trauma
What are the possible manifestations / features of Cerebral Palsy?
Motor Features:
- abnormal tone
- delayed motor & fine motor miles
- abnormal gait
- feeding difficulty
Non-motor Features:
- learning difficulties (60%)
- epilepsy (30%)
- squints (30%)
- hearing impairment (20%)
What are some localizing features of focal seizures?
ie. which part of the brain will produce which symptoms?
Temporal Lobe (most common in focal seizures):
- automatisms:
- Primative oral - lip smacking, random noises
- Primative manual - grabbing, hand rubbing, fiddling, picking at clothes, moving arms
- dysphasia
- hallucinations
- smell
- taste
- sound
- deja vu / jamias vu
- emotional disturbance
- anger
- de-realisation
- anxiety
- panic / terror
Frontal Lobe:
- subtle behaviour changes
- dysphagia / speech arrest
- Motor:
- peddling
- Jacksonian march - clonic movements, which may travel proximally
- post-ictal Todd’s palsy = weakness 24hrs after seizure
Parietal Lobe:
- Sensory disturbances
- tingling
- numbness
- pain (rare
- Motor (if spread to pre-central gyrus)
Occipital Lobe:
- Visual phenomena
- stripes
- dots
- flashes
Generalised seizures can be divided into 2 catagories - what are they?
What the the key features of a generalised seizure?
Types of generalised seizure:
- motor (e.g. tonic-clonic, myoclonic, atonic)
- non-motor (e.g. absence)
Features of generalised seizures:
- Loss of conciousness / awareness
- Postictal confusion / drowsiness (~15 mins) - not specific to generalsied seizures
- Fall stiffly (tonic phase of tonic-clonic)
- Shaking - rigid (tonic) phase + rhythmic clonic jerks afterwards, ↓ in amplitude + frequency
- Blue lips (in tonic-clonic due to ↓ respiratory ability)
- Tongue biting
- Incontinence of urine (non-specific as can occur in syncope)
There are many potential causes of seizures other than epilepsy.
Name as many as you can.
The point is there are TONNES!
Infectious / inflammation:
- Brain abscess
- Encephalitis
- Febrile seizures
- Meningitis
- TB
- HIV encephalitis
- Toxoplasma
Neurological:
- Congenital anomoly
- Degenerative cerebral disease
- Hypoxic ischaemic encephalopathy
- Tuberous sclerosis
- Neurofibromatosis
- Hydrocephalus
Metabolic (lots of hypos):
- Hypocalcaemia
- Hypoglycaemia
- Hyponatraemia
- Hypomagnaesemia
- Inborn error of metabolism
Vascular / trauma:
- Stroke
- Cerebral contusion
- Intracranial haemorrhage
- Child abuse
Drugs:
- Drugs of abuse e.g. cocaine or meth
- Lead poisoning
- Salicylates
- Sympathomimetics
- TCAs
- Withdrawal from benzos / EtOH / seizure meds
Oncological + pre-eclampsia + epilepsy etc etc etc.
What is Encephalomalacia?
Encephalomalacia is a term used to describe …
Softening or loss of brain tissue after a cerebral infarction, ischaemia, infection, cerebral trauma or any other injury!
Image shows an example.
Describe each element of the Child Glasgow Coma Scale:
Eye opening, verbal, motor
What are the features of Migraine headaches?
Migraine is a common type of primary headache
-
Headache - severe, unilateral, throbbing (temporal / front area)
- Bilateral more common in children
- 4-72 hours - can be shorter in children
- GI symptoms (more prominent in children) - nausea, vomiting
- Photophobia & Phonophobia - pts go to quiet, dark room and sleep helps
-
Aura symptoms (10-25% - less common in children)
- visual, progressive, last 5-60 mins
- transient hemianopic disturbance e.g. hemianopia
- scintallating scotoma (area of diminished vision / shimmering white light)
- Not sudden i.e. develop over at least 5 mins
- last 5-60 mins
What are some common triggers for migraines?
- tiredness, stress
- bright lights
- alcohol
- lack of food or dehydration
- cheese, chocolate, red wines, citrus fruits
- COCP
- menstruation
What are the international headache society (IHS) criteria for diagnosing migraines without aura in an adult?
- 5 attacks fufilling criteria 2-5
- Headache lasting 4-72 hrs
- Headache has at least 2 of the following:
- unilateral
- pulsating
- moderate / severe pain
- aggravated by routine physical activity
-
1 of the following during headache:
- nausea and/or vomiting
- photophobia and phonophobia
- Not attributed to another disorder (Hx does not suggest secondary cause)
How are migraines different in children compared to adults?
- Bilateral more than unilateral
- GI symptoms more prominent (nausea / vomiting)
- Aura less likely
What are the international headache society (IHS) diagnostic criteria for paediatric migraine without aura?
- 5 attacks fufilling criteria 2-4
- Headache lasting 1-72 hrs
- Headache has 2 or more of the following:
- bilateral or unilateral (frontal/temporal) location
- pulsating
- moderate / severe pain
- aggravated by routine physical activity
-
1 or more of the following during the headache:
- nausea and/or vomiting
- photophobia and phonophobia
How are migraines managed in children?
- Ibuprofen > paracetamol
-
Triptans e.g. sumatriptan nasal spray
- only in children ≥ 12-yrs
- not well tolerated due to taste
- oral triptans not licensed in < 18-yrs
How are migraines managed acutely in adults?
- 1st line = combination therapy of oral triptan + NSAID / paracetamol
- 2nd line = non-oral prep of metoclopramide or prochlorperazine
- never in children as acute dystonic reaction can occur (involuntary contractions causing abnormal movements / postures)
Name 5 atypical migraine ‘aura’ symptoms that would indicate further investigation.
- Motor weakness
- Diplopia (double vision)
- Visual symptoms affecting only one eye
- Poor balance
- Decreased level of consciousness
Can migraine aura occur without the headache?
Yes!
How is migraine managed prophylactically in adults?
- Prophylaxis given if pt experiences 2 or more episodes per month
- 1st line = Propranolol (beta-blocker) or Topiramate (AED)
- Propranolol in women of child-bearing age as topiramate is teratogenic and reduces effectiveness of hormonal contraceptives
- 2nd line = course of up to 10 sessions of acupuncture over 5-8 weeks
How are febrile seiures managed?
The same way as any other seizure!
- Start with buccal midazolam or rectal diazepam
- Antipyretics or cold sponging = not recommended for fever element
Describe the following types of generalised seizures.
- Absence
- Myoclonic
- Tonic
- Tonic-clonic
- Atonic
Absence:
- 3-10 yr old W > M
- TLOC, sudden onset and termination - absence lasts a few seconds
- no motor phenomena
- look like they are daydreaming
- no memory of seizure period
- can occur several times a day
Myoclonic:
- Brief, often repetitive, jerking movements
- Non-epileptic physiological myoclonus exists e.g. hiccoughs, sleep myoclonus
Tonic:
- Generalised increase in tone
Tonic-clonic:
- Rhythmic cycling between Tonic (increased tone) & Clonic (synchronised contraction of muscle groups)
- Injury due to fall
- Don’t breathe –> cyanosed
- Drool
- Tonge biting
- Urinary incontinence
Atonic:
- Often combined with myoclonic jerk, followed by transient loss of muscle tone –> sudden fall or drop of head
