seizures + paroxysmal events Flashcards
ddx for unresponsiveness
- seizure (post-ictal, eye deviation, rhythmic, incontinence)
- closed head injury (+/- seizure)
- toxic ingestion (+/- seizure)
- BRUE
- apnea
- infection/mengitis/encephalitis
- syncope: cardiac, breath holding
- brain tumor
- intussusception - rare: long pain –> lethargy
- hypoglycemia (–> seizure)
seizure types
generalized
- convulsive (tonic, tonic-clonic, myoclonic)
- absence
focal/partial
- simple (conscious)
- complex (unconscious)
work-up for non-febrile seizures
hx (timeline, post-ictal, precepitating, famhx)
physical
provoking? infection, trauma, meds, toxins, sleep deprivation, stress
test: labs based on hx + physical
- CT or MRI possibly
- if ?meningitis/encephalitis then r/o high ICP before LP
- ECG/holter if ?cardiac
- EEG (acutely or f/u +/- sleep)
- bloodwork for lytes, glucose
treatment for seizures
treat if 2+ unprovoked or 1 /w an abnormal EEG
anti-epileptics
surgeries (stimulators, resection, temp lobectomy, corpus callostomy)
ketogenic diet: infant + young kids not responding to meds
anticipatory guidance: water sports, med alert bracelet
febrile seizure diagnosis & characterstics
fever but no intracranial infection / cause
if prev afebrile seizure, cannot diagnose febrile seizure
is provoked (= not epilepsy)
typical/simple: generalized, <15min, 1 in 24h
complex/atypical: 15+ min, focal features, recurrent in 24hr
RFs: higher fever, fam hx, daycare
Management of febrile seizures
- if child 6mo -6 years, simple/typical, normal neurodev: treat fever + source, no other work-up except as indicated by hx
- LP or further work-up only if meningeal signs/sx, if <1 year /w no source of fever
- if complex then EEG, LP, +/- imaging
counselling for febrile seizures
- seizure safety (nothing in mouth, place on side)
- 1/3 recurr, but only 5% –> epilepsy (more if complex)
- small increased risk /w MMR & DPTP vaccine
- antipyretics don’t prevent
status epilepticus definition (in >1mo old)
seizure >30min or repeated seizures without return to normal
when to start treatment for seizure
if lasts longer than 5 mins
treatment of seizure acutely
- Monitor ABCs, attach monitors, IV access
- rapid glucose test, consider critical labs (lytes, extended lytes).
- Ask re drug allergy.
- After 5min: lorazepam, diazepam or midazolam.
- 5 min more - repeat above
- 5 more min: give fosphenytoin (IV preferred). Can sub phenytoin if needed or phenobarb (resp depression!).
- 5 more min: give phenobarbital (or fosphenytoin if not tried)
after 10 more min: ICU, continuous EEG
if no IV: use IM fosphenytoin, PR paraldehyde
ddx for apnea in infants
- CNS: seizure, breath holding, ICP (bleed, trauma, infection, tumor), NM disorder
- CVS: brady (long QT), duct dependent lesion (eg tet spells) – decompensate at few weeks
- resp: RSV, pertusis, pneumonia, aspiration, asthma, congenital anomaly
- GI: GERD, swallowing issue, TEF (cough, feeding issues), obstruction
- systemic: sepsis, met disorder, botulism, ingestion, CO, hypothermia, hypoglycemia
- ENT: OSA, vasovagal, suffocation
BRUE definition
<1 year old
- cyanosis or pallor
- absent or irreg breathing
- change in tone
- altered LOC
diagnosing brue
dx of exclusion
“low risk”, meets all criteria:
- age >60d
- born 32wks+ and now 45d+ corrected
- no previous BRUE
- duration <1 min
- no CPR by medical provider
- no concerning hx or PE
If does not meet above, needs work-up
subdural hematoma causes
- head trauma
- if /w retinal haemorrhages from shaking
- rarely in delivery (vaccum/forceps), resolves in 4-6wks
- not from short falls, seizures, or CPR
Breath holding spell description
6mo - 6 year olds
cyanotic type: cries after anger usually, apnea in expiration, cyanosis, and LOC /w loss of tone or posturing
pallid type (less common): minor trauma, pallor + LOC, decreased/increased tone
posture is after apnea (vs seizure from start)
clinical dx, can do CBC + ferritin, sometimes anemia
if unclear hx work-up for seizure, cardiac
