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Year 5 - Paediatrics > Seizures/epilepsy (neurological disease in a child) > Flashcards

Seizures/epilepsy (neurological disease in a child) Flashcards

1
Q

How can risk of SUDEP be minimised?

A
  1. Optimising seizure control
  2. Being aware of potential consequences of nocturnal seizures

SUDEP = sudden unexpected death in epilepsy

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2
Q

How soon should patients be seen after their first seizure?

A

Within 2 weeks

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3
Q

Should an EEG be performed even in non-epileptic seizures? When should it be done?

A

No, only in epilesy within 4 weeks of second seizure (in special cases after first seizure)

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4
Q

If the EEG is negative for epilepsy, can it be excluded?

A

No - EEG should not be used to exclude a diagnosis of epilepsy and should not be used alone to make a diagnosis.

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5
Q

How is an EEG best achieved?

A

Through sleep or use of melatonin

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6
Q

When is an MRI indicated in epilepsy?

A
  • if develops before age of 2 years or in adulthood
  • suggested focal onset in history/exam/on EEG
  • when seizures continue despite first-line medication
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7
Q

What other investigations are useful in epilepsy?

A

Other investigations for epilepsy:

  • Urine and serum biochemistry
  • ECG
  • Neuropsychological assessment for learning disabilities and cognitive dysfunction
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8
Q

What headings are used to classify seizures?

A
  1. Description of seizure (ictal phenomenology)
  2. Seizure type
  3. Syndrome
  4. Aetiology

Failure to classify properly can lead to inappropriate treatment and persistence of seizures

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9
Q

Who should not be offered sodium valproate?

A

Women and girls of childbearing age unless other options are ineffective or not tolerated

Offer lamotrigine instead

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10
Q

What is first line for focal seizures?

A

Lamotrigine or carbamazepine*

*carbamazepine not for childbrearing girls/women

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11
Q

What is first line for generalised tonic-clonic seizures?

A

1st line: Sodium valproate (or lamotrigine to childbearing women/girls)

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12
Q

What is first line for absence seizures?

A

1st line: Sodium valproate (or ethosuxamide to childbearing girls/women)

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13
Q

What is first line for myoclonic seizures?

A

1st line: Sodium valproate

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14
Q

What is first line for tonic or atonic seizures?

A

1st line: Sodium valproate

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15
Q

What is first line for infantile spasms?

A

1st line: Steroid (prednisolone or tetracosactide) or vigabatrin

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16
Q

What is first line for:

  1. Childhood absence epilepsy, juvenile absence epilepsy or other absence epilepsy syndromes?
  2. Generalised tonic clonic seizures only
  3. Juvenile myoclonic epilepsy (JME)
  4. Idiopathic generalised epilepsy (IGE)
  5. Benign epilepsy with centrotemporal spikes (BECTS), Panayiotopoulos syndrome, late onset childhood occipital epilepsy (Gastaut type)
  6. Lennox-Gastaut syndrome
  7. Dravet syndrome
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17
Q

What are the risks of pharmacological treatment for epilespy?

A
  • Bone health
  • Neuropsychiatric issues
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18
Q

Is regular blood testing required on epilepsy treatments?

A

Not unless clinically indicated:

  • detection of non adherence
  • suspected toxicity
  • adjusting phenytoin dose
  • managing pharmacokinetic interations
  • clinical conditions like status epilepticus, organ failure and preganncy
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19
Q

How long should the child be seizure free before consideration of withdrawing treatment?

A

2 years - withdrawal done over 2-3 months and 6 months for benzodiazepines and barbituates

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20
Q

Which type of diet may be considered in epilepsy?

A

Ketogenic diet - not an alternative to pharmacological treatment

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21
Q

When is vagus nerve stimulation useful in epilepsy?

A

As adjunctive therapy when refractory to antiepileptic mediation but not suitable for resective surgery. Only in focal seizures or generalised seizures.

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22
Q

How do you manage seizures in the community?

A
  • If seizure lasts 5min or in repeated (3 or more in 1 hour)
    • Buccal midazolam (first line) OR
    • Rectal diazepam
    • If IV access is already established then give IV lorazepam
23
Q

When would you call an ambulance in the community for a seizure?

A

Call ambulance if…

  • 5min after treatment there is no response
  • this is the first episode requiring treatment
  • there is history of serial seqizures or convulsive status epilepticus
  • ABCDE concerns
24
Q

What is the management of convulsive status epilepticus in a hospital setting? (investigations and management)

A

At t= 0 mins:

  • secure airway
  • secure IV access in a large vein
  • access cardiac and respiratory function
  • check blood glucose
  • give high flow oxygen

​Max 2 doses of first line treatment can be given. IV lorazepam is preferred over diazepam/midazolam in the hospital setting.

25
Q

How do you manage refractory convulsive status epilepticus?

A
  • IV midazolam
  • IV thiopental sodium

*for adults you might consider IV propofol. An anaesthetists should be involved by this stage.

26
Q

What must you warn women about AEDs and contraception/pregnancy/breastfeeding?

A

Contraception - enzyme-inducing AEDs can reduce the effectiveness or oral and implant contraceptives e.g. combined pill or progesterone only. Barrier methods should be encouraged.

Pregnancy - women should stop AEDs before pregnancy due to risks of fetal malformations

Breastfeeding - women should be encouraged to breastfeed even on AEDs as this is generally safe

27
Q

What emergency investigations should be done during a seizure?

A

Bloods:

  • BM
  • Blood gases
  • LFTs
  • U&Es
  • Ca and Mg
  • FBC (and platelets)
  • Clotting
  • AED drug levels
  • Toxicology

Urine:

  • Toxicology

Imaging:

  • Chest radiograph (for aspiration)
28
Q

List the drugs used for focal and generalised seizures.

A

Focal seizures: carbamazepine, eslicarbazepine acetate, lacosamide, lamotrigine, levetiracetam, pregabalin and zonisamide.

Generalised seizures: lamotrigine, levetiracetam, sodium valproate and zonisamide

29
Q

What is the dose/kg given of midazolam/lorazepam first line?

A

Midazolam - 0.5mg/kg bucally

Lorazepam - 0.1mg/kg IV

30
Q

What is the dose of phenytoin given 10mins after lorazepam?

A

Phenytoin - 20mg/kg IV over 20 mins

OR (some may be on regular phenytoin so use phenobarbital)

Phenobarbital - 20mg/kg IV over 5 mins

31
Q

Define absence seizure.

A

Behavioural arrest with generalised spike wave activity on EEG.

32
Q

Define atonic seziure.

A

Sudden loss of muscle tone.

33
Q

Define BECTS epilepsy.

A

Benign epilepsy with centrotemporal spikes - epilepsy syndrome of childhood (5-14 years) characterised by focal motor and/or secondary generalised seizures, majority drom sleep, in an otherwise normal individual.

Centrotemporal spikes on EEG.

34
Q

Define childhood absence epilepsy.

A

Age of onset of 4-9 years characterised by frequent absence seizures associated with 3 Hz spike wave activity on EEG.

35
Q

Define CSWS.

A
  • Continuous spike and wave during slow sleep
  • epilepsy syndrome with childhood onset, characterised by plateau and regression of cognitive abilities
  • associated with dramatic increas in spike wave activity in slow wave sleep (>85% of slow sleep).
  • May have few seizures at presentation.
36
Q

Define convulsive status epilepticus.

A

Convulsive seizure lasting for a prolonged period (>5min) or when colvulsive seizures occur one after the other with no recovery between.

This is an emergency and required immediate medical attention.

37
Q

Define Dravet syndrome.

A
  • Previously ‘severe myoclonic epilepsy of infancy’
  • epilepsy syndrome with onset in infancy, characterised by initial prolonged, typically lateralised, febrile seizures,
  • subsequent development of multiple seizure types including myoclonic, absence, focal and generalised toni-clonic
  • with developmental plateau or regression
38
Q

Define generalised tonic-clonic seizure.

A

A seizure of sudden onset involving generalised stiffening and subsequent rhythmic jerking of the limbs, the result of rapid widespread engagement of bilateral cortical and subcortical networks in the brain.

Person might bite their tongue and be incontinent. They may feel sleepy afterwards and take a while to recover.

39
Q

Define tonic seizure .

A

Abrupt generalised muscle stiffening possibly causing a fall. Seizure usually lasts less than a minute and recovery is rapid.

40
Q

Define SUDEP.

A

Sudden unexpected death in epilepsy

sudden, unexplained, witnessed or unwitnessed, non-traumatic and non-drowning death in people with epilepsy, with or without evidence for a seizure, and excluding documented status epilepticus in which post-morted does not reveal a toxicological or anatomic cause for death

41
Q

Define refractory status epilepticus.

A

Status epilepticus despite treatment with two anticonvulsants in appropriate doses. Can occur in both convulsive and non-convulsive status epilepticus.

42
Q

Define Panayiotopoulos syndrome,

A

Epilepsy syndrome in childhood presenting early (mean 4-7 years) with rare seizures that are prolonged.

Characterised by autonomic features including vomiting, pallor and sweating followed by tonic eye deviation, impairment of consciousness and possible evolution into a secondarily generalised seizure.

Prognosis excellent and treatment usually unnecessary

43
Q

Define NEAD.

A
  • Non-epileptic attack disorder
  • Episodes of change in behaviour or movement
  • Not caused by a primary change in electrical activity in the brain
  • Movements are varied, and attacks can be difficult to differentiate from epileptic seizures
44
Q

Define non-convulsive status epilepticus.

A

Change in mental status or behaviour from baseline, associated with continuous seizure activity on EEG, changing from baseline.

45
Q

Define myoclonic seizure.

A

Sudden brief (<100ms), shock-like involuntary single or multiple jerks due to abnormal excessive or synchronous neuronal activity

associated with polyspikes on EEG

46
Q

Define Doose syndroeme/MAE?

A
  • Myoclonic-astatic epilepsy
  • Age of onset is 18-60 months
  • Characterised by different seizure types with myoclonis and myoclonic astatic seizures seen in all causing children to fall
  • EEG shows generalised spike/polyspike and wave activity at 2-6 Hz
47
Q

Define Lennox–Gastaut syndrome.

A

Onset at 3-10 years

Characterised by multiple seizure types (including atonic, tonic, tonic-clonic and atypical absence seizures), cognitive impairmnet and

specific EEG features of diffuse slow spike and wave (<2Hz) as well as paroxysmal fast activity (10Hz or more) in sleep

48
Q

Define late-onset childhood occipital epilepsy (Gastaut type).

A

Age of onset in mid-childhood to adolescence with frequent brief seizures characterised by initial visual halluscinations, ictal blindness, vomiting and post-ictal headache.

EEG shoes interictal occipital spikes attenuated by eye opening

49
Q

Define Landau-Kleffner syndrome (LKS).

A

Rare epilepsy syndrome with onset at 3-6 years

Characterised by loss of language (after a period of normal language development)

Associated with an epilepsy of centrotemporal origin, bitemporal spikes on EEG with enhancement in sleep or continuous spike and wave during slow sleep

50
Q

Define Juvenile myoclonic epilepsy (JME).

A

Age of onset 5-20+ years (peaking at 10-16 years) characterised by myoclonic seizures that most commonly occur soon after waking

Absence and generalised tonic-clonic seizures may occur in between 50-80% of people with JME.

EEG shows 3-6 Hz generalised polyspike and wave activity, with photosensitivity in more than 30% of people .

51
Q

Define juvenile absence epilepsy.

A
  • Age of onset 9-13 years characterised by absence seizures
  • Associated with 3-4Hz spike wave on EEG
  • Generalised tonic-clonic seizures may occur
52
Q

Define infantile spasms.

A

Seziure type presenting in the first year of life, most commonly between 3-9 months.

Spasms are brief axial movements lasting 0.2-2 seconds, most commonly flexor in nature, involving flexion of the trunk with extension of the upper and lower limbs. Occasionally called ‘salaam seizures’.

53
Q

Define idiopathic generalised epilepsy (IGE).

A

Well defined group of disorders characterised by typical absences, myoclonic and generalised tonic-clonic seizures, alone or in varying combinations in otherwise normal individuals.

EEG characteristic showing distinct pattern of generalised polyspike wave discharges and/or generalised spike wave.

Presumed to have genetic aetiology and sometimes called GGE (genetic generalised epilepsy)

Year 5 - Paediatrics (91 decks)

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