Suspected Seizure Flashcards
What is the initial management of status epilepticus?
After 5 min of fitting
If vascular access:
IV/IO lorazepam (0.1 mg/kg)
If no: Buccal Midazolam (0.5mg/kg) Rectal Diazepam (0.5mg/kg)
What is the second stage of management of status epilepticus if patient is still fitting?
After 10 mins of fitting
IV/IO Lorazepam (0.1 mg/kg)
CALL FOR SENIOR HELP
If not on phenytoin: Prepare phenytoin
If already on phenytoin: Prepare phenobarbitone
Optional: Paraldehyde (0.8ml/kg 50:50 infusion with oil) Give while preparing phenytoin (DO NOT DELAY PHENYTOIN)
What is the third stage of management of status epilepticus?
Reconfirm it is an epilectic seizure
Seek anaesthetic/ICU advice
Not on phenytoin: Give phenytoin (20mg/kg) given IV/IO over 20 minutes
On phenytoin: Give phenobarbitone (20mg/kg) given IV/IO over 20 minutes
What is the fourth step in the management of status epilepticus?
Anaesthetist must be present
Rapid Sequence Induction (RSI) with thiopental
Child’s GCS
Eye Opening
E4 Spontaneous E3 To voice E2 To pain E1 None C Eyes closed (by swelling or bandage)
Child’s GCS
Motor
M6 Obeys commands Normal spontaneous movements
M5 Localises to supraorbital pain (>9 months of age) or withdraws to touch
M4 Withdraws from nailbed pain
M3 Flexion to supraorbital pain (decorticate)
M2 Extension to supraorbital pain (decerebrate)
M1 No response to supraorbital pain (flaccid)
Child’s GCS
Verbal
V5 Orientated Alert, babbles, coos, words or
(in person or place or address) sentences to usual ability (normal)
V4 Confused Less than usual ability, irritable cry
V3 Inappropriate words Cries to pain
V2 Incomprehensible sounds Moans to pain
V1 No response to pain
T Intubated
Differential Diagnosis for a child with seizure
Febrile seizure Encephalopathy Encephalitis/meningitis Post-ictal Sepsis/shock Brain tumour Epilepsy Metabolic disorder - The younger the unconscious child, the higher the possibility of a metabolic cause for being persistently unconscious/encephalopathic or intractable seizures. Family history of infant deaths. Poisoning/intoxication - Similarly, should be actively ruled out in any patient, if persistent encephalopathic
Other conditions to consider in an unconscious child include: Trauma/ head injury, hypertension, hydrocephalus
Questions to ask parents about a seizure
Prior to the episode
During Episode
Post-Episode
Recent Illness
Prior to episode (10)
Behavioural change Health that day Circumstances Time of episode Setting Activity at onset Warning: visual, hearing, fear, sweaty, light headedness Objective warning Triggers Time of last meal
During episode (14)
Onset- sudden? Unresponsive Awareness Symmetrical? Facial movement Eye movements Posturing Motor movements Clonic/ myoclonic/spasm or tonic Breathing changes Incontinence Autonomic Visual disturbance Duration of seizure
Post-Episode (7)
Sleepy/disorientated Nausea, vomiting Amnesia for events Strange behaviour Weakness Injuries: tongue Time to recovery
Recent Illness (11)
fever chestiness diarrhoea weight loss Recent headaches Head injury/trauma visual disturbances vomiting or nausea personality change poor co-ordination new weakness Taken drug/substance
What is epilepsy?
Tendancy to intermittent abnormal electrical brain activity
1% of children will have a seizure (not associated with fever) by the age of 14
At least two unprovoked seizures occurring >24 h apart
One unprovoked seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years
Diagnosis of an epilepsy syndrome
What is the difference between partial epilepsy and generalised epilepsy?
Partial epilepsy: Can be localised to one part of a hemisphere
Generalised: Cannot be localised
What is the difference between complex and simple seizures?
Complex: Loss of consciousness
Simple: No loss of consciousness
Seizures in generalised epiliepsy (4):
Tonic/Clonic: Limb stiffness (tonic), jerking forcefully (clonic) with LOC
Absences (petit mal): Brief(10secs) pauses (stop mid sentence), eyes may roll up, unaware of the attack
Infantile Spasms/West syndrome: Clusters of head nodding (Salaam attacks) and arm jerks every 3-30 seconds; Peak age: 5 months; reduced IQ in ~70%; Rx 1,prednisolone 2,vigabitrin (ACTH)
Myoclonic seizures: 1-4 years e.g thrown suddenly to the ground Rx: Valproate
What is a simple febrile convulsion?
Single tonic-clonic, symmetrical generalised seizure Last <15 minutes
Occurrs as temperature rapidly rises in a febrile illness Typically in a normally developing child (6months - 6years)
~3% of children have at least one febrile convulsion
When could a febrile convulsion be more sinister?
Focal CNS signs or CNS abnormality
Previous history of epilepsy
Seizure last >15 mins
There is >1 attack in 24 hours
Think:
Meningo-encephalitis, CNS lesion, epilepsy, trauma, ↓glucose, ↓Ca2+, ↓Mg2+
Differntial diagnosis for epilepsy
Arrythmias (prolonged QT) Migraine Narcolepsy Night terrors Reflex anoxic seizures (excessive vagus nerve activity) Munchausen's
What is a complex febrile seizure?
Last >15 minutes
More than 1 episode in 24 hours
Associated with post ictal neuroligical abnormalities
Simple: <15 mins, one within 24 hours,
Not caused by an acute disease of the nervous system, in a child aged 6 months to 5 years, with no neurologic deficits
What are the indications for an urgent CT head for someone who has had an afebrile seizure?
Encephalopathic or coma
Suspected raised intracranial pressure
Progressive neurological deficit
What are the indications for an elective CT head for someone who has had an afebrile seizure?
In a child under 2 year of age at onset
hard focal neurological signs
a focal epilepsy
associated significant learning difficulties
an epilepsy resistant to full doses of 2 appropriate drugs
In what circumstances is an EEG indicated?
Urgent Indications:
Suspected non-convulsive status
Non traumatic encephalopathy
Coma of unknown cause
Elective standard EEG if:
Strong suspicion of epilepsy (to support classification)
Developmental or language regression
NOT generally after a first afebrile seizure or febrile seizures
What aspects of a seizure do you parents need to be counselled on?
Counselling on recurrence risk of fever related seizures and risk of epilepsy.
First aid training and what not to do in a convulsive seizure (especially not to put something into the child’s mouth or do chest compressions)
They maybe considered for training to administer rescue medication, buccal midazolam for example, at 5 minutes.
Need to be aware of when to call an ambulance (e.g. after 5 minutes of a convulsive seizure, or if rescue medication was ineffective after 5 minutes)
Follow up arrangements, by either their Consultant, or a referral to an epilepsy specialist
What is the significance of early hand preference?
Early hand preference before 12 months have a higher risk of hemiplegia of the non-dominant side
What are the possible causes of delayed walking?
Central causes: delayed maturation (constitutional); global developmental causes (e.g. genetic/chromosomal disorders with often hypotonia or dysmorphism); all causes of hemiplegia often with hypertonia including cerebral palsy
Peripheral: spinabifida
Muscular and neuromuscular diseases: such as Duchenne Muscular dystrophy
Enviromental: bottom shufflers, institutionalised (chronically ill, prematurity, gross pycho-social deprivation)
Orthopaedic: developmental dysplasia of the hip
Metabolic/hormonal: Hypothyroidism, rickets, mucopolysaccharidosis
What is Sturge-Weber syndrome?
Rare disorder characterized by the association of a facial birthmark- port-wine birthmark
Neurological abnormalities
Eye abnormalities such as glaucoma
What is Todd’s paralysis?
Experienced by peple with epilepsy,
Seizure is followed by a brief period of temporary paralysis
Paralysis may be partial or complete but usually occurs on just one side of the body
