Suspected Seizures

Question 1

What are the risk factors suggesting a predisposition for epilepsy?

Answer 1

o Premature birth.
o Complicated febrile seizures.
o A genetic condition that is known to be associated with epilepsy, such as tuberous sclerosis or neurofibromatosis.
o Brain development malformations – usually associated with epilepsy developing before adulthood.
o A family history of epilepsy or neurologic illness.
o Head trauma, infections (for example meningitis, encephalitis), or tumours — can occur at any age.
o Comorbid conditions such as cerebrovascular disease or stroke — more common in older people.
o Dementia and neurodegenerative disorders (people with Alzheimer’s disease are up to ten times more likely to develop epilepsy than the general population).

Question 2

Which questions should you ask about a seizure?

Answer 2

o Any subjective symptoms at the start of the seizure (aura) — suggestive of focal epilepsy; these may provide information on where the seizure might arise.

o Any potential triggers, for example sleep deprivation, stress, light sensitivity, or alcohol use.

o Specific features of the seizure, for example:

• Short-lived (less than 1 minute), abrupt, generalised muscle stiffening (may cause a fall) with rapid recovery — suggestive of tonic seizure.
• Generalised stiffening and subsequent rhythmic jerking of the limbs, urinary incontinence, tongue biting —suggestive of a generalised tonic-clonic seizure.
• Behavioural arrest — indicative of absence seizure.
• Sudden onset of loss of muscle tone — suggestive of atonic seizure.
  -Brief, ‘shock-like’ involuntary single or multiple jerks —suggestive of myoclonic seizure.

o Residual symptoms after the attack (post-ictal phenomena), such as drowsiness, headaches, amnesia, or confusion (usually occur only after generalised tonic and/or clonic seizures).

Question 3

Which questions should you ask specifically about what happened prior to the seizure?

Answer 3

o Behavioural change
o Health that day
o Circumstances
o Time of episode
o Setting
o Activity at onset
o Warning: visual, hearing,
fear, sweaty, light headedness
o Objective warning
o Triggers
o Time of last meal

Question 4

Which questions should you ask specifically about what happened during the seizure?

Answer 4

o Onset- sudden?
o Unresponsive
o Awareness
o Symmetrical?
o Facial movement
o Eye movements
o Posturing
o Motor movements
o Clonic/ myoclonic/spasm or tonic
o Breathing changes
o Incontinence
o Autonomic
o Visual disturbance
o Duration of seizure

Question 5

Which questions should you ask specifically about what happened after the seizure?

Answer 5

o Sleepy/disorientated
o Nausea, vomiting
o Amnesia for events
o Strange behaviour
o Weakness
o Injuries: tongue
o Time to recovery

Question 6

Which questions should you ask to find out if there were any recent illnesses before the seizure?

Answer 6

o fever
o chestiness
o diarrhoea
o weight loss
o Recent headaches
o Head injury/trauma
o visual disturbances
o vomiting or nausea
 personality change
o poor co-ordination
o new weakness
o Taken drug/substance

Question 7

Which examinations do you perform when assessing a seizure?

Answer 7

Cardiac, neurological, and mental state, and a developmental assessment if appropriate.

Examination of the oral mucosa to identify lateral tongue bites.

Identification of any injuries sustained during the seizure.

Question 8

Which investigations do you perform when assessing a seizure?

Answer 8

Consider arranging baseline tests for adults with suspected epilepsy, and send the results to the specialist, when available. These may include:

Bloods such as full blood count, urea and electrolytes, liver function tests, glucose, and calcium.

A 12-lead electrocardiogram (ECG).

EEG

Question 9

What are the differentials for seizures?

Answer 9

• Vasovagal syncope.
• Cardiac arrhythmias.
• Panic attacks with hyperventilation.
• Non-epileptic attack disorders (psychogenic non-epileptic seizures, dissociative seizures, or pseudoseizures).
• Transient ischaemic attack.
• Migraine.
• Medication, alcohol, or drug intoxication.
• Sleep disorders.
• Movement disorders.
• Hypoglycaemia and metabolic disorders.
• Transient global amnesia.
• Delerium or dementia — altered awareness may be mistaken for seizure activity.

Question 10

What are the differentials for seizures in children?

Answer 10

o Febrile convulsions
o Breath-holding attacks
o Night terrors
o Stereotyped/ritualistic behaviour- especially in those with a learning disability.

Question 11

What is the management of a first seizure?

Answer 11

Children and adults who have had a suspected first seizure should be referred urgently (within 14 days) to an epilepsy specialist (children do not routinely require referral following a febrile convulsion).

Treatment is usually not recommended until after a second epileptic seizure but may be indicated after a first seizure if the individual has a neurological deficit, brain imaging shows a structural abnormality, the electroencephalograph (EEG) shows unequivocal epileptic activity or the individual or their family considers the risk of having a further seizure unacceptable

Question 12

What is febrile convulsion?

Answer 12

A febrile seizure can be defined as a seizure accompanied by fever (temperature higher than 38°C by any method), without central nervous system infection, which occurs in infants and children aged 6 months to 5 years.

A seizure occurring in childhood after one month of age associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure, and not meeting criteria for other acute symptomatic seizures.

Febrile seizures are the commonest form of childhood seizure up to the age of 2 years.

Question 13

What is the classification of febrile convulsions?

Answer 13

Simple 
Complex 
Febrile status epilepticus
Febrile myoclonus seizures 
Afebrile convulsions in young children with mild gastroenteritis

Question 14

What is simple febrile seizures?

Answer 14

Simple febrile seizures are isolated, generalised, tonic-clonic seizures lasting less than 15 minutes, that do not recur within 24 hours or within the same febrile illness, with complete recovery within one hour.

Question 15

What is complex febrile seizures?

Answer 15

Complex febrile seizures have one or more of the following features: a partial (focal) seizure (movement limited to one side of the body or one limb); duration of more than 15 minutes; recurrence within 24 hours or within the same febrile illness; or incomplete recovery within one hour.

Question 16

What is febrile status epilepticus?

Answer 16

Febrile status epilepticus describes a febrile seizure that lasts for 30 minutes or longer, or there are a series of seizures, without full recovery, lasting for 30 minutes or longer.

Question 17

What is the aetiology of febrile convulsions?

Answer 17

• Exact mechanisms are unknown.
• It is uncertain whether the degree of fever or the rate of rise of temperature is a trigger in febrile seizures.
• Genetic factors are involved: there is a family history of febrile seizures in 24%. Inheritance patterns are probably polygenic, although in a few families a particular gene or autosomal dominant inheritance has been identified.
• Environmental factors

Question 18

What are the environmental factors for febrile seizures?

Answer 18

o Viral infections (cause of fever in 80% of cases)
o Otitis media
o Tonsillitis
o UTI 
o Respiratory tract infections

Other causes of fever with seizure are:
o Gastroenteritis
o Post-immunisation (rare): vaccination with diphtheria-tetanus-pertussis and MMR may be associated with an increased risk of febrile seizures but this is not a CI to vaccination.

Question 19

Which serious illness need excluding when assessing febrile seizures?

Answer 19

o Meningitis and septicaemia
o UTI
o Cerebral malaria (if hx is suggestive of it)
o Lower respiratory tract infection

Question 20

What are the risk factors for febrile convulsions?

Answer 20

• About 50% of children who present with a febrile seizure have no identified risk factors.

Known risk factors include:
• Family history of febrile seizure in first-degree relatives. The more relatives affected, the greater the risk.
• The peak temperature (rather than the speed of the temperature rise).
• Iron and zinc deficiency

Question 21

What are the typical clinical features of a simple febrile seizure?

Answer 21

• Suspect a diagnosis of febrile seizure if a child has a fever or febrile illness and a reported or witnessed seizure

• Typical features of a simple febrile seizure include:
o The child is aged 6 months to 6 years.
o The seizure usually lasts 2–3 minutes, and rarely lasts more than 10 minutes.
o The seizure is a generalized tonic-clonic type (muscle stiffening followed by rhythmical jerking or shaking of the limbs, which may be asymmetrical); twitching of the face; rolling back of the eyes; staring and loss of consciousness.
o There may be foaming at the mouth, difficulty breathing, pallor, or cyanosis.
o A brief post-ictal period of drowsiness, irritability, or confusion, with complete recovery within 1 hour.
o The child may have had a previous febrile seizure.

Question 22

What are the typical clinical features of a complex febrile seizure?

Answer 22

o A partial onset or focal features (movement limited to one side of the body or one limb).
o The seizure lasts more than 15 minutes.
o There is seizure recurrence within 24 hours or within the same febrile illness.
o There is incomplete recovery within 1 hour, and there may be prolonged post-ictal drowsiness or transient hemiparesis (Todd’s palsy).

Question 23

How should you assess a child suspected of having febrile seizure?

Answer 23

Assess for:
o Red flag symptoms and signs for conditions such as meningtis, encephalitis and manage appropriately.
o Other conditions that may mimic a febrile seizure.

Ask about:
o If fever was associated with the seizure.
-Reported parental perception of fever should be accepted as a valid indicator of fever.
-Be aware that fever can occur any time during or after a seizure, and the majority of febrile seizures occur within 24 hours of fever onset.
o When the fever started, peak temperature and duration, and any associated symptoms to suggest an underlying cause of febrile illness.
o The relationship of the onset of fever to the seizure.
o The characteristics and duration of the seizure, to help classify whether it is simple or complex.
o The duration of any post-ictal drowsiness.
o Any previous seizure episodes.
o Any recent antibiotic use (may mask signs of central nervous system infection).
o Any recent immunizations, missed immunizations, or unknown immunization history.
o Neurodevelopmental history and any concerns.
o Whether the child attends daycare such as nursery (source of potential exposure to infection).
o Any family history of febrile seizures or epilepsy.

Question 24

Which examinations should you do in a child presenting with a febrile seizure?

Answer 24

o Assess the level of consciousness and check for any focal neurological deficit such as weakness of the hand, arm, or leg.
o Check the temperature after the seizure has ended.
o A temperature of more than 38°C is generally considered significant.
o Assess fluid status and for signs of dehydration.
o Assess for other signs to identify the underlying cause of febrile illness, and manage appropriately.
o Assess for stigmata of a neurocutaneous or metabolic disorder suggesting another cause.

Question 25

Which investigations should you do in a child presenting with a febrile seizure?

Answer 25

Consider measuring blood glucose if a child cannot be roused or is having an acute seizure episode, if possible and appropriate.

Consider urine dipstick analysis and urine microscopy and culture if there is no clear focus for infection and the underlying cause of fever is uncertain.

Question 26

Differentials of febrile seizure with fever

Answer 26

o CNS infection such as meningitis or encephalitis.
o Rigors or delirium (acute confusional state)
o Shivering — a perception of cold and involuntary muscle tremors that persist for several minutes. There is no loss of consciousness or involvement of facial or respiratory muscles.
o Febrile myoclonus — a benign disorder causing myoclonic jerks usually involving the upper limbs during fever. They may last from 15 minutes to several hours.

Question 27

Differentials of febrile seizures without fever

Answer 27

o Syncope
o Breath-holding spells or reflex anoxic seizures
o Head injury.
o Hypoglycaemia or other metabolic disorders, such as a mitochondrial cytopathy — metabolic disorders may present with developmental delay, faltering growth, hepatosplenomegaly, and micro or macrocephaly.
o Drug use or withdrawal.
o Epilepsy- suspect if there is no compelling history of fever, the seizure was complex, there were post-ictal signs, or there is neurodevelopmental delay.
o Epilepsy syndromes
onOther neurological conditions such as cerebral palsy or neurocutaneous syndromes where seizures may form part of the condition.

Question 28

What is syncope?

Answer 28

A transient loss of consciousness due to insufficient cerebral blood flow, often caused by hypotension.

It is characterized by a rapid onset, short duration, and spontaneous complete recovery.

Question 29

What is a reflex anoxic seizure?

Answer 29

A brief, involuntary cessation of breathing often triggered by sudden unexpected fright, fear, or pain.

May present with pallor or cyanosis and low tone, with possible loss of consciousness and transient tonic clonic movements if the apnoea is prolonged.

Question 30

Examples of epilepsy syndromes

Answer 30

Dravet syndrome (severe myoclonic epilepsy of infancy) — a neurodevelopmental disorder characterized by prolonged intractable seizures initially triggered by fever. Typically over time seizures change to become myoclonic and later focal, with developmental delay associated.

Genetic epilepsy with febrile seizures plus (GEFS+) — an autosomal dominant disorder where seizures continue beyond 6 years of age, and afebrile seizures may also occur.

Question 31

Name some neurocutaneous syndromes

Answer 31

Sturge-Weber syndrome may be suggested by a unilateral port-wine stain over the trigeminal area.

Tuberous sclerosis may be suggested by facial angiofibromas, shagreen or leather patches, periungual fibromas, and hypopigmented macules (‘ash-leaf spots’).

Neurofibromatosis may be suggested by cafe au lait spots, intertriginous freckling, iris hamartomas, and subcutaneous nodules.

Question 32

What is the advise for parents on how to manage febrile convulsions at home?

Answer 32

Most children will present to a healthcare professional after the febrile seizure has resolved.

Advise parents/carers that if a child is having a suspected acute febrile seizure, advice below should be followed:
Immediate first aid:
o Note the duration of the seizure.
o Protect from injury during the seizure by cushioning their head with your hands or soft material, and removing harmful objects from nearby/moving the child away from immediate danger.
o Do not restrain the child or put anything in their mouth.
o Check the airway and place the child in the recovery position when the seizure has stopped.
o Observe the child until they have recovered.
o Check for any injuries that may have been caused by the seizure.

Question 33

What should a parent do if seizures last for more than 5 minutes?

Answer 33

If tonic-clonic movements last for more than 5 minutes:
o Call an emergency ambulance; or
o Give emergency benzodiazepine rescue medication if this has been advised by a specialist for a child with recurrent febrile seizures: buccal midazolam or rectal diazepam. Both may be repeated once after 10 minutes if the seizure has not stopped.

Question 34

When should a parent call an ambulance when a child is having a febrile seizure?

Answer 34

10 minutes after the first dose of rescue medication, the seizure has not stopped, the child has ongoing twitching or another seizure has begun before the child regains consciousness.

There is suspected meningitis/meningococcal disease, encephalitis, or any other suspected serious or life-threatening cause of fever, such as pneumonia or sepsis.

Question 35

When should an immediate hospital assessment be arranged for a febrile seizure?

Answer 35

Arrange immediate hospital assessment by a paediatrician if:
o It is the first presentation of febrile seizure (or a subsequent febrile seizure and the child has not had previous specialist assessment).
o The child is less than 18 months of age (clinical signs of central nervous system infection may be subtle or absent).
o There is uncertainty about the cause of the seizure.
o There are any features of a recurrent complex febrile seizure.
o There is any focal neurological deficit.
o There was a decreased level of consciousness prior to the seizure.
o The child has recently taken antibiotics (may mask the signs of central nervous system infection).
o There is parental/carer anxiety and/or difficulty coping.

• Consider urgent hospital assessment for a period of observation if the child has unexplained fever and no apparent focus of infection.

• Arrange referral to a paediatrician or paediatric neurologist for further assessment, the urgency depending on clinical judgement, if:
o The child has neurodevelopmental delay and/or signs of a neurocutaneous syndrome or metabolic disorder.

Question 36

What advice should be given to parents after their child has febrile seizure?

Answer 36

• Explanation is important, as seizures can be very frightening for parents.

The following points should be covered and a leaflet provided:
• What febrile seizures are:
o Febrile seizures are not the same as epilepsy, and the risk of a child developing subsequent epilepsy is low.
o Short-lasting seizures are not harmful to the child.
o About 1 in 3 children will have another febrile seizure.
o The risk of febrile seizure reduces with age as the brain matures, and they are rare beyond 6 years of age.

• How to treat fever at home - remove excess clothing, give fluids, give antipyretics if the child is uncomfortable. Tepid sponging or excessive cooling are not recommended. Check for a non-blanching rash, check for dehydration and stay with the child at night.
• First aid if the child has a fit - position; do not put anything in their mouth.
• When to call 999/112/911 ambulance - a seizure lasting more than five minutes.
• When and how to seek urgent medical advice - any seizure, serious symptoms such as non-blanching rash, lack of normal alertness, dehydration, the child getting worse, the parent worried and fever for more than five days.
• Advise parents to ensure the child completes all childhood immunisations even if the febrile seizure followed an immunization.