Pediatric Seizures Flashcards
Are seizures common or uncommon in children?
Common
What percentage of children will have a sz prior to 16 y/o?
4-6%
What is the most common (~50%) cause of first time sz in children?
Fever (febrile sz)
What is the 2nd most common (~35%) cause of first time seizure in children?
Idiopathic
(Generalized/Partial) sz involve (the entire brain/one hemisphere of the brain)? (answer both)
Gen: entire
Partial: one hemisphere
Is a tonic-clonic sz a generalized or partial sz?
generalized
Is an absence sz generalized or partial?
generalized
Is a simple sz generalized or partial?
partial
Is an atonic sz generalized or partial?
generalized
Is a myoclonic sz generalized or partial?
generalized
Why do you want to position a pt on their side if they are having a sz?
To avoid aspiration of drool or vomit
What are medication options for patients having a sz lasting >3 min?
Lorazepam IV or IM, Diazepam IV or PR, Midazolam IV IM or intranasal
After assessing the ABCs on a pt having a sz, what 5 things should you do/check?
Place O2, measure O2 Sat, Monitor CV, obtain IV access, measure a bedside glucose (Accucheck)
From what three time periods do you want to obtain a history on a pt who has had a sz?
Pre sz, sz itself, post-sz (post ictal time)
In what direction do eyes tend to deviate during a tonic clonic sz?
upwards
Can abx be a precipitating cause of sz? Other medications?
Yes and yes–always ask about recent abx, adult Rx/toxic ingestions i.e. ethylene glycol
What are some factors that may predispose a child to sz?
Hx of hydrocephalus, hardware in the brain, prior meningitis, head trauma, immunosuppressed predisposition to CNS infection, hypercoagulable states i.e. Sickle cell dz
Why should formula mix not be diluted?
This can lead to very low sodium levels which can precipitate a sz in a young child
When taking the temperature on a child following a sz, where is the best location?
Rectal temp is best
What are some signs of increased ICP in a young child?
bulging fontanelles, papilledema
What condition may predispose children to sz and presents with skin lesions like Ashleaf spots, shagreen patch, and café au lait?
Tuberous sclerosis
A febrile sz is a seizure associated with a fever ___ F (most have temp ___ F) in children ___ y/o
> 100.4 F; >102 F; <6 y/o
Can a child w/ temp of 101.5F be diagnosed with febrile sz if they have a history of prior afebrile seizures?
No
T/F A child w/ a temperature of 101F can be diagnosed with febrile sz when they have an acute metabolic abnormality
false, they cannot
If a patient has a temp of 102F and has no meningeal signs and no signs of CNS infection, can they be dx’d with a febrile sz?
Yes
What is the typical age range of children diagnosed with febrile sz?
6 mo-6 y/o
During what age range is there a peak of febrile sz dx?
12-18 months
On what day of illness does a febrile sz usually occur?
The first day (Day 1)
T/F Febrile sz can only occur with viral infections
F, they can occur with bacterial and viral
Which two viruses are the culprit of a majority of febrile sz?
HHV-6, influenza
After what vaccinations are children at an increased risk of having a febrile sz?
DTP and MMR (up to 14 days following vaccination!)
Are febrile sz familial?
Yes, 10-20% of parents/siblings also have febrile sz
Simple febrile seizures last ____ (usually ____), they are (Partial/Generalized), (with/without) focal features, and (do/do not) recur within 24 hrs.
<15 min; 2-3 min; generaliZed; without, do not
Complex febrile seizures last ____, (with/without) focal features, and (do/do not) recur within 24 hrs.
> 15min; with; do
What is Todd’s paralysis?
postictal paralysis
When evaluating a patient following their first simple febrile sz, what labs or imaging are NOT necessary?
Labs, EEG, and Neuroimaging are not necessary nor beneficial. If anything, assess for cause of fever (i.e. UTI = UA, cough w/ fever = CXR, etc)
If the patient is back to baseline and neurologically intact, should you perform an LP?
No need
In a pt with febrile sz, who is < 12 months, should an LP be considered?
Yes, Strongly considered!
In a pt with febrile sz, who is 12-18 months, should an LP be considered?
Yes, considered
In a pt with febrile sz, who has prior abx tx, should an LP be considered?
Yes, strongly considered
Why are S. pneumoniae and H. Influenza less likely causes of bacterial meningitis these days?
People have been vaccinated now
Does meningitis manifest with sz other than a febrile sz, or can it manifest as a febrile sz alone?
According to the retrospective study by Green et al
no pts had meningitis manifesting solely as a simple febrile seizure
Those that had bacterial meningitis presented with prolonged focal seizure, multiple seizures, generalized petechia, and nuchal rigidity
What is the utility of LP for simple febrile szs in children 6-18 months who have received appropriate immunizations and have not been pre tx’d with abx?
Not very useful as the percentage of children in this age group with ABM is extremely low and in several studies none of the CSF cx grew a bacterial pathogen
What are some features of a child that increase the risk of acute bacterial meningitis?
Illness > 3 days; first rapid rise in temperature
Physician visit within last 48 hrs
Current antibiotics for extracranial infection
Immunocompromised
Unvaccinated child
Multiple seizures/back-to-back sz
Prolonged post-ictal phase
What would some PE findings be that would be concerning for ABM?
Focal neurological deficits Altered motor tone Nuchal rigidity Poor perfusion Generalized petechiae
What is the incidence of acute bacterial meningitis in children with SE and fever? Would LP be indicated?
~ 12%; Yes–once sz stops, ABCs have been assessed, and pt is stable
What percentage of pts will experience recurrent febrile seizure? What are some factors that increase recurrence risk?
33% Young age onset (< 1 year) FHx of febrile sz Baseline developmental delay Complex febrile sz
What percentage of pts will develop epilepsy after having a first time febrile sz?
2%
T/F Reduction in temperature w/ acetaminophen or ibuprofen reduces the risk of subsequent febrile seizures?
False
T/F Neither continuous or intermittent anticonvulsant therapy is recommended for children w/ simple febrile szs
True; can use rectal diazepam prn
While a pt is having a sz, should the caregiver or individual present, place something in the pts mouth to prevent them from biting their tongue?
NO, do not do this, pt can choke
T/F Chin lift and jaw thrust are important components of maintaining a pts airway during a sz
T
While most pts who have had a first time febrile sz can be discharged home, what are some indications for admission of these pts?
Prolonged postictal phase
Complex febrile seizure
Age < 6 months
Social concerns (Inability of caretakers to provide appropriate observation, Prolonged distance to medical care)
What is absence epilepsy?
Absent staring with/without eyelid flutter
In pts w/ Juvenile myoclonic epilepsy, when are myoclonic jerks greater in incidence?
the morning
When is the onset of Juvenile Myoclonic Epilepsy? (general)
adolescence
What is a precipitating factor of Juvenile Myoclonic Epilepsy? (provide example)
Precipitated by stressors (lack of sleep etc)
What types of sz might a pt with Juvenile Myoclonic Epilepsy experience?
May have tonic-clonic and absence seizures as well
In a pt with Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic), what are some signs/sx they may present with?
Somatosensory changes (numbness/tingling), speech arrest, facial twitching, drooling
In a pt with Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic), will the pt have this condition for life?
A lot of children will outgrow these szs
What medications are recommended for tx of Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic)?
Neurologists will often not recommend medications etc for tx
However: Can use same AEDs used to treat partial seizures, and they are often responsive to carbamazepine
In a pt with Benign Epilepsy of Childhood with Centrotemporal Spikes (BECTS/Rolandic), when might they experience sz? What type of sz will they have?
May have tonic clonic seizures at night, often during sleep
What are infantile spasms? Are they more or less concerning than other sz types?
Sudden flexion, extension or mixed movements of trunk and proximal muscles
More concerning and tx’d w/ greater urgency
What is the typical age of onset for Lennox Gastaut Syndrome? What types of sz will these pts have?
3-5 years
Mixed sz types
T/F Pts w/ Lennox Gastaut Syndrome can be expected to function at a normal cognitive level as other children their age
False, most children have severe developmental delay
As part of the evaluation of epilepsy syndrome, providers (will/will not) need to order a(n) (urgent/non-urgent) EEG and MRI, with exception to what condition?
Will; non-urgent (outpatient); infantile spasms (Need urgent EEG, MRI, and metabolic evaluation with neurology consultation)
Mortality with infantile spasms is as high as ___-___% and only ___-___% of children with infantile spasms have normal intelligence.
15-20%; 5-10%
In pts with infantile spasms, there is a high association with what other medical condition?
Tuberous sclerosis
In a pt with epilepsy syndrome who is experiencing absence sz, what are the pharmaceutical treatments of choice?
Ethosuximide, valproic acid, lamotrigine, levetiracetam
In a pt with Juvenile Myoclonic Epilepsy, what are the pharmaceutical treatments of choice?
Valproic acid, topiramate, levetiracetam
In a pt with Infantile Spasms, what are the pharmaceutical treatments of choice?
ACTH (Adrenocorticotropic hormone), steroids, zonisamide, topiramate, vitamin B-6
In pts with seizures w/o epilepsy syndrome, lab evaluation should be based on individual clinical circumstances (H&P) and may include…
Electrolytes (glucose, Ca, Mg, Phos)
Ammonia, Lactic Acid (if metabolic syndrome suspected)
Drug Screen (possible toxin exposure)
LP + Antibiotics
An emergent ___ should be ordered if the pt shows focal neuro signs, or signs of intracranial mass effect such as AMS, papilledema, bulging fontanelle. Otherwise, a ___ is generally not indicated in pts w/ sz w/o epilepsy syndrome.
CT
A(n) ___ is superior to CT in detecting epileptogenic foci
MRI
EEG helps determine ___, ___, and ___. An EEG (does not need to be/should be) performed after all first nonfebrile, unprovoked seizures.
sz type, presence of an epilepsy syndrome, risk for recurrence
Should be
A majority of children w/ first unprovoked seizure (will/will not) have many recurrences
will not
only ~10% will go on to have many seizures
Treatment with AED after a first seizure as opposed to after a second seizure (has/has not) been shown to improve prognosis for long-term seizure remission
Has not
Do you or do you not admit patients with infantile spasms?
ALWAYS ADMIT
What is the most common cause of neonatal sz?
Hypoxic Ischemic Encephalopathy
What is the common first-line treatment of neonatal sz?
Phenobarbital
