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Year 4 - Paediatrics > Paeds - Suspected Seizure > Flashcards

Paeds - Suspected Seizure Flashcards

1
Q

What are the steps for managing status epilepticus in a child

> 1-month old?

A

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
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2
Q

In a child with suspected seizure what questions do you want to ask the parents regarding ‘prior to the episode’?

A
  • 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
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3
Q

In a child with suspected seizure what questions do you want to ask the parents regarding ‘during the episode’?

A
  • 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
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4
Q

In a child with suspected seizure what questions do you want to ask the parents regarding ‘after the episode’?

A
  • Sleepy / disorientated
  • Nausea / vomiting
  • Amnesia of events
  • Strange behaviour
  • Weakness
  • Time taken to recover
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5
Q

In a child with suspected seizure what questions do you want to ask the parents regarding ‘recent illness’?

A
  • head injury/trauma
  • fever
  • diarrhoea
  • weight loss
  • headaches
  • visual disturbances
  • vomiting / nausea
  • poor co-ordination
  • weakness
  • taken drug/substance
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6
Q

What are indications for urgent head MRI or CT in children?

A
  1. Encephalopathy or coma
  2. Suspected raised intracranial pressure
  3. Progressive neurological deficit
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7
Q

What are the indications for elective head MRI in a child?

A
  1. child < 2-year of age at onset
  2. hard focal neurological signs
  3. focal epilepsy
  4. significant learning difficulties
  5. an epilepsy resistant to full doses of 2 appropriate drugs
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8
Q

What are febrile convulsions?

A

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
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9
Q

What is the link between febrile convulsions and epilepsy?

A

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:
    1. FHx of epilepsy
    2. Complex febrile convulsions
      • i.e. > 15 mins, focal not generalised, repeat episodes in < 24hrs)
    3. 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)
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10
Q

What are the features of febrile convulsions?

A

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
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11
Q

What are the types and features of febrile convulsions?

A

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
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12
Q

EEG’s are not suggested for abfrebile seizures!

But what are some indications for urgent EEG?

A
  1. Suspected non-convulsive status
  2. Non traumatic encephalopathy
  3. Coma of unknown cause

Elective EEG:

  • Strong suspicion of epilepsy (to support classification)
  • developmental or language regression
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13
Q

What epilepsy questions might you have for a patient in A&E presenting with collapse with TLOC?

A
  • 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?
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14
Q

What epilepsy questions might you have for an observer of a patient in A&E presenting with collapse with TLOC?

A
  • 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
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15
Q

How is a seizure managed actuely?

A
  • 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
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16
Q

What investigations would you do after an acute seizure?

A

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
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17
Q

A pt has a focal seizure of one of their temporal lobes - what symptoms might they experience?

A

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
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18
Q

Besides the PC / HPC - what other specific

questions are useful in a seizure history?

A
  • 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
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19
Q

Name factors which can ↑ an epileptic pt’s liklihood of having a seizure.

A
  1. Illness e.g. LRTI or UTI
  2. Poor concordance with AED medication
  3. 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
  4. Alcohol excess
  5. Metabolic disturbances e.g. hypo-/hyper-natraemia, hypoglycaemia, hypocalcaemia (↓ Ca)
  6. Disturbed sleep, jetlag, fatigue
  7. GI disturbances which cause poor AED absorption
20
Q

What guidance might parents of a child who has experienced a febrile seizure / or any seizure need?

A
  1. Counselling on recurrence risk of febrile seizure / seizures + risk of epilepsy
  2. 1st aid training on what to do / not to do e.g. don’t put anything in child’s mouth or do chest compressions)
  3. Consider training to administer rescue meds e.g. buccal midazolam at 5 mins
  4. 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
  5. Follow up appointments by either a Consultant or refer to epilepsy specialist
21
Q

Before what age is a child having a hand preference considered abnormal?

What is early hand preference associated with?

A

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
22
Q

What are the major developmental milestones for

Social Behaviour and Play?

A
23
Q

What are the major developmental milestones for

Speech and Hearing?

A
24
Q

What are the major developmental milestones for

Gross Motor?

A
25
Q

What are the major developmental milestones for

Fine Motor & Vision?

A
26
Q

In a child what form of brain imaging is preferred?

A

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
27
Q

What is Cerebral Palsy?

A

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
28
Q

What causes Cerebral Palsy?

A

Antenatal (80%) causes:

  • cerebral malformation
  • congenital infection (e.g. rubella, toxoplasmosis, cytomegalovirus)

Intrapartum (10%):

  • birth asphyxia / trauma

Postnatal (10%):

  • intraventricular haemorrhage
  • meningitis
  • head trauma
29
Q

What are the possible manifestations / features of Cerebral Palsy?

A

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%)
30
Q

What are some localizing features of focal seizures?

ie. which part of the brain will produce which symptoms?

A

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
31
Q

Generalised seizures can be divided into 2 catagories - what are they?

What the the key features of a generalised seizure?

A

Types of generalised seizure:

  1. motor (e.g. tonic-clonic, myoclonic, atonic)
  2. 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)
32
Q

There are many potential causes of seizures other than epilepsy.

Name as many as you can.

A

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.

33
Q

What is Encephalomalacia?

A

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.

34
Q

Describe each element of the Child Glasgow Coma Scale:

Eye opening, verbal, motor

A
35
Q

What are the features of Migraine headaches?

A

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
36
Q

What are some common triggers for migraines?

A
  • tiredness, stress
  • bright lights
  • alcohol
  • lack of food or dehydration
  • cheese, chocolate, red wines, citrus fruits
  • COCP
  • menstruation
37
Q

What are the international headache society (IHS) criteria for diagnosing migraines without aura in an adult?

A
  1. 5 attacks fufilling criteria 2-5
  2. Headache lasting 4-72 hrs
  3. Headache has at least 2 of the following:
    1. unilateral
    2. pulsating
    3. moderate / severe pain
    4. aggravated by routine physical activity
  4. 1 of the following during headache:
    1. nausea and/or vomiting
    2. photophobia and phonophobia
  5. Not attributed to another disorder (Hx does not suggest secondary cause)
38
Q

How are migraines different in children compared to adults?

A
  1. Bilateral more than unilateral
  2. GI symptoms more prominent (nausea / vomiting)
  3. Aura less likely
39
Q

What are the international headache society (IHS) diagnostic criteria for paediatric migraine without aura?

A
  1. 5 attacks fufilling criteria 2-4
  2. Headache lasting 1-72 hrs
  3. Headache has 2 or more of the following:
    1. bilateral or unilateral (frontal/temporal) location
    2. pulsating
    3. moderate / severe pain
    4. aggravated by routine physical activity
  4. 1 or more of the following during the headache:
    • nausea and/or vomiting
    • photophobia and phonophobia
40
Q

How are migraines managed in children?

A
  1. Ibuprofen > paracetamol
  2. Triptans e.g. sumatriptan nasal spray
    • only in children ≥ 12-yrs
    • not well tolerated due to taste
    • oral triptans not licensed in < 18-yrs
41
Q

How are migraines managed acutely in adults?

A
  • 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)
42
Q

Name 5 atypical migraine ‘aura’ symptoms that would indicate further investigation.

A
  1. Motor weakness
  2. Diplopia (double vision)
  3. Visual symptoms affecting only one eye
  4. Poor balance
  5. Decreased level of consciousness
43
Q

Can migraine aura occur without the headache?

A

Yes!

44
Q

How is migraine managed prophylactically in adults?

A
  • 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
45
Q

How are febrile seiures managed?

A

The same way as any other seizure!

  • Start with buccal midazolam or rectal diazepam
  • Antipyretics or cold sponging = not recommended for fever element
46
Q

Describe the following types of generalised seizures.

  • Absence
  • Myoclonic
  • Tonic
  • Tonic-clonic
  • Atonic
A

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

Year 4 - Paediatrics (16 decks)

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