Suspected Seizures Flashcards
What are the risk factors suggesting a predisposition for epilepsy?
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).
Which questions should you ask about a seizure?
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).
Which questions should you ask specifically about what happened prior to the seizure?
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
Which questions should you ask specifically about what happened during the seizure?
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
Which questions should you ask specifically about what happened after the seizure?
o Sleepy/disorientated o Nausea, vomiting o Amnesia for events o Strange behaviour o Weakness o Injuries: tongue o Time to recovery
Which questions should you ask to find out if there were any recent illnesses before the seizure?
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
Which examinations do you perform when assessing a seizure?
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.
Which investigations do you perform when assessing a seizure?
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
What are the differentials for seizures?
- 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.
What are the differentials for seizures in children?
o Febrile convulsions
o Breath-holding attacks
o Night terrors
o Stereotyped/ritualistic behaviour- especially in those with a learning disability.
What is the management of a first seizure?
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
What is febrile convulsion?
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.
What is the classification of febrile convulsions?
Simple Complex Febrile status epilepticus Febrile myoclonus seizures Afebrile convulsions in young children with mild gastroenteritis
What is simple febrile seizures?
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.
What is complex febrile seizures?
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.
What is febrile status epilepticus?
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.
What is the aetiology of febrile convulsions?
- 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
What are the environmental factors for febrile seizures?
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.
Which serious illness need excluding when assessing febrile seizures?
o Meningitis and septicaemia
o UTI
o Cerebral malaria (if hx is suggestive of it)
o Lower respiratory tract infection
What are the risk factors for febrile convulsions?
• 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
What are the typical clinical features of a simple febrile seizure?
• 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.
What are the typical clinical features of a complex febrile seizure?
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).
How should you assess a child suspected of having febrile seizure?
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.
Which examinations should you do in a child presenting with a febrile seizure?
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.