Seizure Paeds Flashcards
A 12 months old boy presents with a fever of 39.7 degrees measured rectally. He has a Hx of SVT treated successfully at birth with Propanalol. 2 minutes into the Hx, the child becomes dazed and even more lethargic, Shortly after he has a generalised tonic-clonic seizure. O/E you do not find any rashes. What is the most likely Dx and what is your management?
- Febrile Seizure
- Meningitis
- Encephalitis
- Epilepsy
- Febrile Seizure
- Febrile seizures common in those aged 6 months - 6 years and are associated with infections, typically viral as the body temperature increases
- The child will become less arousable and then have a generalised tonic-clonic seizure
Management
- Secure airway and reassure parents
- IV access with VBG, FBC, CRP, U&E, LFT and Calcium
- If seizure continuing after 5 minutes = IV Lorazapam or Buccal Medazolam if no access (5mg as they are aged 1- 4yrs) (300ug/kg up to 2.5 if <6 months, 2.5mg if 6-11 months and 7.5mg if 5-9yrs)
- If seizure continuing after further 10 minutes (15 total) = Senior help, 2nd dose of IV Lorazapam and prepare Phenytoin or Phenobarbitone if already on Phenytoin
- If continuing after further 10 minutes (25 total) = Senior team will deliver phenytoin or phenobarbitone
- If seizing after 45 minutes total = Senior team will rapid sequence induced the child
Simple if general, lasting <5 minutes and doesn’t recoccur
Complex if >5 minutes, focal or reoccurring within 24hrs
How do you manage a Febrile seizure after the event
- Assess the child using NICE traffic light system (Golden Hr management if infection suspected, unstable or unconscious)
- Explain events and educate parents:
- What is a febrile seizure
- What have we done
- What is a postictal state
- Risk of reoccurrence (30-40%) and epilepsy (1-2% if
simple and 4-12% if complex) - What to do in a seizure (Protect, do not restrain,
airway and support - Dr if <5 minutes and
ambulance if >5 minutes) - How to manage Fever (Para and/or Ibu + undress to
let the child loose heat naturally - DO NOT SPONGE
DOWN ETC)
- Refer to Paeditrician if:
- 1st event or 2nd event with no prior review
- Complex
- Postictal state lasting >1 hr
A 12 months old boy presents with a fever of 39.7 degrees measured rectally and reduced appetitie. He has a Hx of SVT treated successfully at birth with Propanalol. 2 minutes into the Hx, the child becomes dazed and even more lethargic, Shortly after he has a generalised tonic-clonic seizure. O/E you do not find a non-blanching rash. What is the most likely Dx and what is your management?
- Febrile Seizure
- Meningitis
- Encephalitis
- Epilepsy
- Meningitis
- Infants cannot communicate classical traid so present with fever, lethargy/irritability, anorexia. More severe signs or reduced consciousness, hypotonia, respiratory distress and shock (tachy with reduced cap refill)
- The presence of the non-blanching rash suggests possible meningococcal meningitis.
- The seizure could be a febrile seizure but you do not want to risk missing meningitis and thus a full work-up should be conducted once the seizure is managed.
If this was outside of hospital, you would Tx the seizure, asses the child using the NICE traffic light system, urgently refer them to hospital and give IM Ben-Pen
Inside of hospital
- Tx seizure as per Status Epilepticus protocol
- Give IV Ceftriaxone as suspected bacterial meningitis (+ Amoxicillin if < 3months and vancomycin if recent travel)
Ix
- FBC, CRP, U&E and ABG
- Blood culture and Rapid N.Meningitidis antigen test
NORMAL FBC, CRP AND BLOOD CULTURE/RAPID ANTIGEN DOES NOT EXCLUDE BACTERIAL MENINGITIS
- CT if signs of raised ICP or Focal seizure (DO NOT DELAY Tx)
- LP for CSF (If bacterial = turbid with raised granulocytes and low glucose)
- PCR if culture negative
Tx - Alter appropriately once Pathogen found
- Oral Dexamethasone (0.15mg/kg up to 10mg) QDS for 4 days if bacterial
- IV Ceftriaxone if typical ( 7 days for N.Menin, 10 days for HiB and 14 days for Strep.Pneumo)
- Change to IV Cefotaxime for 14 days if group-B strep
- Change to IV Amoxicillin for 21 days + IV Gentamycin for 7 days if Listeria
- Change to IV Cefotaxime for 21 days if Gram -Ve bacilli
What are the common causes of Bacterial Meningitis in different age groups?
< 3 months
- Group-B strep
- E.coli
- Listeria
3months - 6 years = Typicaly
- N.Meningitidis
- Strep Pneumoniae
- HiB
> 6yrs = Typical - HiB
- Strep and Neisseria
What are the contraindications to a LP?
- Raised ICP = Reduced consciousness, Papilloedema, Abnormal pupil responses, Cushing’s response (HTN and Brady)
- Focal neuro deficits/seizures
- Haemodynamic stability
- Coagulopathy/Purpura
- Infection at puncture site
- LP causing delay to Tx
What are the signs of severe Meningitis/Encephalitis?
- Reduced consciousness
- Hypotonia
- Respiratory distress
- Shock
- Seizures
- CN Palsies
- Bulging Fontanelles and signs of raised ICP
What are the differences between Encephalitis and Meningitis?
Meningitis and Encephalitis present in very similar ways but:
- Encephalitis is more likely to be viral
- Personality changes more pronounced in Encephalitis
- Seizures tend to be more focal and affect temporal lobe in encephalitis (ataxia, aphasia)
- Wider array of rashes related to viral infection in Encephalitis
Describe the management of Encephalitis?
- Assess using NICE traffic light + Hx and Exam
- Start IV Aciclovir (10mg/kg) every 8hrs for 10-21hrs if encephalitis suspected
Ix
- FBC, CRP and Serology
- Throat Swab and Nasopharyngeal aspirate for enetro/resp viruses
- CT/MRI (CT good for general review of focal seizures/personality changes - MRI more detailed showing inflammation and oedema)
- LP (Virus = Clear, lymphocytosis and normal glucose)
- MC&S + PCR for specific pathogen
Tx
- Once pathogen confirmed
- EBV, VZV and HSV = Aciclovir
- CMV, Herpes B and HHV6 = Ganciclovir
- Bacteria = Antibiotics
- Automimmune = steroids or other immunosuppressants
- Supportive therapy
What are the complications of Encephalitis
- Short term = High likelihood of death without Tx as well as SIADH and Diabetes Insipidus (medium risk)
- Long term = Seizures and Epilepsy (medium risk)
Describe the difference between a focal and generalised seizure?
- Focal = isolated to specific regions of the brain with symptoms varying depending on the location. Simple = consciousness unaffected, Complex = reduced or loss of consciousness
- Generalised seizures affect the entire cerebral cortex with impaired consciousness
Describe the different presentations of a focal seizure?
Frontal
- Tonic = Raised arms for a short period
- Clonic = Contraction in certain muscle groups that begin distally and may move proximally (Jacksonian march)
Temporal
- An aura/premonitory symptom if old enough to communicate (deja vu, epigastric pain etc.)
- Automatism (repetitive, simple movements)
- Often have impaired consciousness that lasts longer than for absent generalised seizures
Occipital
- Visual disturbances
Parietal
- Contralateral sensory deficits
Describe the different forms of generalised seizure?
Absent
- Acute onset loss of awareness for <10 second with no motor dysfunction and normal consciousness resumed immediately after
GTC
- Tonic phase during which the patient will often fall followed by clonic contractions
- Patients eyes are often open with tongue biting and incontinence common
Tonic
- Sudden increase in muscular tone
Atonic
- Sudden loss of tone and consciousness
Myoclonic
- Jerking movements of a single or group of muscles
How do you manage a seizure?
Acute = Status Epilepticus guidelines
- Secure airway and reassure parents
- IV access with VBG, FBC, CRP, U&E, LFT and Calcium
- If seizure continuing after 5 minutes = IV Lorazapam or Buccal Medazolam if no access (5mg as they are aged 1- 4yrs) (300ug/kg up to 2.5 if <6 months, 2.5mg if 6-11 months and 7.5mg if 5-9yrs)
- If seizure continuing after further 10 minutes (15 total) = Senior help, 2nd dose of IV Lorazapam and prepare Phenytoin or Phenobarbitone if already on Phenytoin
- If continuing after further 10 minutes (25 total) = Senior team will deliver phenytoin or phenobarbitone
- If seizing after 45 minutes total = Senior team will rapid sequence induced the child
Chronic depends on seizure type
Absent
• 1st line = Sodium Valproate or Ethosuximide (Do not offer Ethosuximide if risk of tonic-clonic)
- If unsuitable, not tolerated or ineffective = Lamotrigine
• 2nd line = combination of 2 of the following: Lamotrigine, Sodium Valproate or Ethosuximide
• 3rd line = refer to specialist
Women = DO NOT GIVE SODIUM VALPROATE
Focal
• 1st line = Carbamazepine or Lamotrigine
- Levetiracetam, Oxcarbazepine or Sodium Valproate if above unsuitable or not tolerated
• 2nd line If 1st AED used is ineffective= any one of the above 5 not previously used
• Adjunct if 1st AED used is ineffective = Any of the above not used or gabapentin, topiramate or clobazam
Women = DO NOT GIVE SODIUM VALPROATE
GTC
• 1st line drugs = Sodium Valproate
- Lamotrigine if Sodium Valproate is unsuitable (may exacerbate myoclonic or absent seizures so use with discretion)
- Carbamazepine or Oxcarbazepine if SV or Lamotrigine unsuitable (May exacerbate myoclonic or absent seizures so use with discretion)
• Adjunct if 1st line not tolerated or ineffective = Clobazam, Levetiracetam or Topiramate
Women = DO NOT GIVE SODIUM VALPROATE
Myoclonic
• 1st line = Sodium valproate
- Levetiracetam or Topiramate if SV unsuitable or not tolerated (Topiramate has a less favourable side effect profile)
• Adjunct = Any of the above 3 not used previously
• 3rd line = refer to specialist
Women = DO NOT GIVE SODIUM VALPROATE
Tonic or atonic
- 1st line = sodium valproate
- Adjunct = Lamotrigine
- 3rd line = Refer to specialist
PACES Counselling
o Explain the seizure
o Explain epilepsy is a tendency to have unprovoked seizures if they have it
o Promote independence and confidence but be away of seizures (Educate about how to respond)
o The school should be made aware of the condition
o Avoid situations where having a seizure could lead to injury or death (e.g. deep baths, swimming unsupervised)
o Driving is only allowed after 1 year free of seizures
