Seizures & epilepsy Flashcards
Seizure reoccurence after afrebrile seizure?
1/3 over the next 2 years and 50% of these occur in next 6 months
How common are febrile seizures?
3% of children
In what ages do febrile seizures occur?
6mo-6yo
Reconsider Dx if outside these ages
Presentation of febrile convulsions?
GTCS, lasting 15 minutes
Occur once in a febrile illness
Onset is sudden
Complex: >15min, occur in same illness
- R/F = previous afebrile seizures, CNS infection, underlying neurological condition
Ix and Tx of febrile convulsions?
No standard, treat specific infection
- EEG is not indicated
Educate parents: benign, no risk of intellectual impairment/brain damage
1/3 chance of recurrence, especially if young
No effect of panadol on risk
Risk of epilepsy in febrile convulsions
Slightly increased: 3% with no other risk factors
If have other R/F: risk can increase up to 10%
Risk of epilepsy in febrile convulsions
Slightly increased: 3% with no other risk factors
If have other R/F: risk can increase up to 10%
Breath-holding spells epidemiology and natural Hx
Very common in toddlers: start at 1-2yo, resolve by 3-4yo
Benign, no risk of death/ID etc. (reassure parents)
May be linked to iron def anaemia
Presentation of breath-holding spells
Precipitated by emotional or physical trauma
Hold breath, become bradycardic, cyanotic/pale
May have hypoxic jerks/convulsive movements
May become floppy and LOC which will terminate event
Recovery is rapid, but may be drowsy
EEG for breath-holding spells
Not necessary
First presentation of the seizure - what are important points to ask on history?
Eye witness account of actual seizure
Previous seizure events?
Before - warning/prodrome/aura, precipitant? (fatigue, alcohol, fever, lights, reading/writing)
Context - febrile/illness, dehydration, environment, activity at time, time of the day/sleeping
After - Consequences/injuries from seizure, drowsiness/confusion
PMHx, FHX and social as per normal
First presentation of the seizure - what are important examination?
Conscious state, vitals ABCD if relevant Neurological exam - focal signs, meningism, raised ICP Development - i.e. dysmorphic features Bedside BGLs
First presentation of the seizure - what possible DDx?
Syncope - vasovagal/cardiac Epilepsy Normal - day-dreaming, sleep jerking Breath holding Movement disorders Sleep related disorder Behavioural/psychiatric Migraine variants
First presentation of the seizure - what Ix would you perform?
Bloods - glucose, electrolytes
EEG - if afebrile
? MRI if suspected mass effect as cause
What is the definition of epilepsy?
> = 2 unprovoked seizures
What are the causes of seizures?
Structural - mass/raised ICP, sclerosis Metabolic - electrolytes, glucose, metabolic disorders Infective - CNS, high fever Vascular - CVA Idiopathic Birth injury/hypoxia Head trauma
What are precipitating factors for epileptic seizures?
Fatigue, sleep deprivation Stress Flashing lights Reading/writing Alcohol Drugs Withdrawal Hypoglycaemia Fever Electrolytes Hypoxia
What are the differences between genetic (idiopathic/primary) and structural/metabolic (secondary/symptomatic) seizures?
Primary
- Age dependent (different for different syndromes)
- associated with specific epileptiform EEGs but otherwise generally well and no neurological features.
- FHX
- Good prognosis and control of seizures
Secondary
- Variable but usually young age presentation
- Variable findings on EEG but generally abnormal neurological exam or developmental delay
- Generally poor prognosis and control of seizures
- Typically history of prior cerebral insult - i.e. hypoxia in birth, CNS infection with scarring
What are the general clinical features of tonic-clonic and absence seizures?
Tonic-clonic
- Tonic-stiffening, eyes open, moan/cry
- Clonic-rapid jerking movements
- Usually last 1-5mins
- Cyanosis or plethora
- Post-ictal confusion, drowsiness or agitation
Absence
- Brief pauses <10s
- Sudden with no warning
- Generally look blank
- May have associated automatisms
- Remain upright
What Ix are useful in afebrile seizures and why?
EEG
- All afebrile seizures have one
- Epileptiform patterns can help diagnosis specific types of epilepsy
- Helps characterise seizure, direct medication choice and need for futher brain imaging
- Video EEG may be helpful as inter-ictal usually normal
- Can’t exclude epilepsy purely on normal EEG
Brain imaging
- If suspect structural cause
- MRI better than CT
What are the first aid instructions for managing seizures?
- Time seizure from onset
- Do not hold/restrict child but remove obstacles and support head with something soft
- Do not put anything in their mouth
- Once seizure finished put in recovery position and call ambulance
- If seizure lasting >3-4 minutes provide rectal or buccal benzo (diazepam or midazolam)
What advice do you give parents when providing diagnosis of epilepsy?
- Explanation of diagnosis and condition
- Reassure that medications to control it and if idiopathic generally good prognosis and ~25% grow out of it
- Discuss triggers to seizures and avoidance
- Discuss management plan - first aid advice, instructions on providing cessation medication if seizure prolonged
- Discuss safety re heights, water (swimming, baths, showers), driving, high-risk hobbies
- Medications - monotherapy usually, slowly titrate up, S/E (ataxia, drowsiness, tremor, N+V, mood disturbance, rash) and may need some monitoring of levels
What is status epilepticus and the Rx?
- Prolonged seizure >10 mins
- Can cause hypoventilation - hypoxaemia and hypercarbia - cardiac arrest, brain damage, MSK injury
- Prepare treatment and provide if lasting >~4m
- Rectal, buccal or IV diazepam or midazolam
- Prepare for ventilation support - O2, CPAP, ventilation
- Investigations - BGLs, U&Es, CMP, septic screen, blood gas
