Seizures Flashcards
What differentials should be considered in a child with a seizure?
Epilepsy Febrile convulsions Breath-holding attacks Reflex anoxic syncope Syncope (fainting) Benign paroxysmal vertigo Pseudo-seizures Migraine Others: Cardiac arrhythmias (long QT), Self-gratification, Tics, daydreaming, night terrors and Sandifer syndrome.
What are the most important questions to ask in the history of a child with a seizure?
What happened before seizure
What happened during seizure (e.g. tongue biting) and how long
What preceded the seizures – was there a post ictal state
How are epileptic seizures categorised
Generalised: involving the whole brain
Focal (partial epilepsy) – frontal, temporal occipital
Simple vs complex = reduced consciousness or not
What is west syndrome?
Infantile spasms (west syndrome) – 5 months clusters of head nodding and arm jerks every 3-30secs. Treat with prednisolone 1st line and vigabatrin 2nd line. Often associated with serious underlying condition – treat with ACTH/corticosteroids and vigabatrin, pyridoxine or ketogenic diet
What is lennox-gastaut syndrome?
Lennox-Gastaut syndrome – may be extension of infantile spasms, 1-5yrs, atypical absence with falls and jerks, majority have mental handicap.
What is benign rolandic epilpesy?
• Benign Rolandic epilepsy – more common in boys than girls, unilateral facial paraesthesia upon waking up
What is juvenile myoclonic epilepsy or Janz syndrome?
• Juvenile myoclonic epilepsy (Janz syndrome) – typically teen girls, infrequent generalised seizures in morning, daytime absence and sudden shock like myoclonic seizure – usually responds well to valproate
What is a tonic-clonic or grand mal seizure?
Tonic-Clonic (grand mal) – limbs stiffen then jerk forcefully with loss of consciousness. Treat with carbamazepine or sodium valproate
What are absence seizures or petit mal?
Absence seizures (petit mal) Common; starts at 4-7 years; resolves in adolescence. Brief episodes of unresponsiveness (no more than 10 seconds). Associated motor activity: repetitive purposeless movements of finger/mouth e.g. lip smacking (called automatisms); eye fluttering/flickering. Treat with ethosuximide then sodium valproate then lamotrigine and failing those 3 try combinations
What are myoclonic seizures?
Myoclonic seizures – child suddenly thrown to the ground – treated with valproate
How are partial seizures treated?
Partial seizures – treat with carbamazepine or lamotrigine
What causes epilepsy?
Often none is found but can be as a result of:
Infection
Hyponatraemia or another electrolyte imbalance
Hypoglycaemia
Any kind of cerebral trauma
How should a seizures be investigated?
Expert EEG MRI (CT in emergency situations) ECG U&E Glucose Temperature Lumbar puncture
How should seizures be managed in an emergency?
ABCDE and get help
Secure airway and give oxygen
Secure IV access
Check BP, pulse, glucose, Ca and Mg
Start a clock
Check temperature, if raised give rectal paracetamol
After 5 minutes if seizures continue give lorazepam IV or buccal midazolam
After 15 mins of seizures continue repeat dose of lorazepam or midazolam, prep phenytoin
After 20 mins give phenytoin or phenobarbital then call anaesthetist and prep for intubation
After 40 mins call PICU
How is epilepsy managed in the long term?
Prophylaxis with sodium valproate (generalised) or carbamazepine (partial)
Use one drug only and increase dose until fitting stops
Only start after 2nd seizure
What general advice should be given to parents of children diagnosed with epilepsy?
Showers safer than baths
Compliance importance due to kindling (one seizure reduced threshold for next)
Cannot drive until 6-month seizure free
Advise re women of child bearing age and those on contraception
What are febrile convulsions?
A single (within 24 hours) tonic clonic symmetrical generalised seizure occurring as a result of a rise in temperature in a normal child.
When must you rule out specific causes of seizure in a child before diagnosing febrile convulsion?
Must rule out meningoencephalitis, CNS lesions epilepsy, trauma or electrolyte disturbance if: focal CNS signs or CNS abnormality, previous history of epilepsy, seizure lasts >15mins or there is more than one seizure within 24 hours
What is a simple febrile convulsion?
<15mins
Generalised seizure
No recurrence within 24 hours
Completely recover within an hour
What is a complex febrile convulsion?
15-30mins
Focal seizure
May repeat within 24 hours
What is status epilepticus?
Seizure lasting >5 minutes
How should febrile convulsions be managed?
Febrile convulsions are very common
Must find the source of the high temperature and exclude meningitis
Whilst seizure is occurring put in recovery position
If it lasts longer than 5 mins then give IV lorazepam, buccal midazolam or diazepam PR
What advice and reassurance can you give the parents of a child with a febrile convulsion?
Reassure parents and give safety netting advise – always ring ambulance if lasts > 5min
Increased risk of more febrile convulsions – 1in 3 risk
Treat any pyrexical illness early with paracetamol
Only increased risk of epilepsy if seizures are complex
What are reflex anoxic seizures?
Reflex anoxic seizure describes a syncopal episode (or presyncope) that occurs in response to pain or emotional stimuli. It is thought to be caused by neurally-mediated transient asystole in children with very sensitive vagal cardiac reflexes.
What age group typcially experience reflex anoxic seizures?
It typically occurs in young children aged 6 months to 3 years.
What are the typical features of a reflex anoxic seizure?
Typical features • Child goes very pale • Falls to floor • Secondary anoxic seizures are common • Rapid recovery
What explanation should you give to the parents of a child who is experiencing reflex anoxic seizures?
When discussing with parents describe as breath holding attacks and that child usually grows out of it.
If you are unsure about the diagnosis of reflex anoxic seizure what investigation can be done?
If unsure can refer to vagal excitation tests under ECG and EEG
