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Neonatal Seizures

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Neonatal Seizures

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    1. NEONATAL SEIZURES Dr Laxman S Sirur MD (Org. of Medicine) www.similima.com 1

    2. Definition Neonatal period limited to : - first 28 days for term infants - 44 weeks gestational age for pre-term www.similima.com 2

    3. The Definition of a Seizure “paroxysmal discharge of cerebral neurons, sufficient to cause clinically detectable events that are apparent, either to the subject or to an observer” www.similima.com 3

    4. Why do neonatal seizures have such unusual presentations? Immature CNS cannot sustain a synchronized, well orchestrated generalized seizure www.similima.com 4

    5. Probable Mechanisms of Some Neonatal Seizures PROBABLE MECHANISM DISORDER Failure of Na + -K + pump secondary to Hypoxemia, ischemia, ? adenosine triphosphate and hypoglycemia Excess of excitatory neurotransmitter (eg.glutamic acid—excessive excitation) Hypoxemia, ischemia and hypoglycemia Deficit of inhibitory neurotransmitter Pyridoxine dependency (i.e., relative excess of excitatory neurotransmitter) Membrane alteration— ? Na + Hypocalcemia and Permeability hypomagnesemia _________________________________________________________________ Volpe JJ.Neonatal Seizures:Neurology of the Newborn.4th ed. www.similima.com 5

    6. Classification of Neonatal Seizures Clinical Electroencephalographic www.similima.com 6

    7. Classification I. Clinical Seizure Subtle Tonic Clonic Myoclonic www.similima.com 7

    8. Classification II. Electroencephalographic seizure Epileptic Non-epileptic www.similima.com 8

    9. Clinical Classification 1. Subtle More in preterm than in term Eye deviation (term) Blinking, fixed stare (preterm) Repetitive mouth and tongue movements Apnea Pedaling and tonic posturing of limbs www.similima.com 9

    10. Clinical Classification 2. Tonic Primarily in Preterm May be focal or generalized Sustained extension of the upper and lower limbs (mimics decerebrate posturing) Sustained flexion of upper with extension of lower limbs (mimics decorticate posturing) Signals severe ICH in preterm infants www.similima.com 10

    11. Clinical Classification 3. Clonic Primarily in term Focal or multifocal Clonic limb movements(synchronous or asynchronous, localized or often with no anatomic order of progression) Consciousness may be preserved Signals focal cerebral injury www.similima.com 11

    12. Clinical Classification 4. Myoclonic Rare Focal, multifocal or generalized Lightning-like jerks of extremities (upper > lower) www.similima.com 12

    13. Electroencephalographic seizure I. Epileptic Consistently associated with electro-cortical seizure activity on the EEG Cannot be provoked by tactile stimulation Cannot be suppressed by restraint of involved limb or repositioning of the infant Related to hyper synchronous discharges of a critical mass of neuron www.similima.com 13

    14. Electroencephalographic seizures II. Non-epileptic No electro-cortical signature Provoked by stimulation Suppressed by restraint or repositioning Brainstem release phenomena (reflex) www.similima.com 14

    15. Jitteriness Versus Seizure CLINICAL FEATURE JITTERINESS SEIZURE Abnormality of gaze or eye O + movement Movements are stimulus + O sensitive Predominant movement Tremor Clonic jerking Movements cease with passive + O flexion Autonomic changes O + ------------------------------------------------------------------------------------------------------------------ www.similima.com 15

    16. NEONATAL SEIZURES Aetiology: Hypoxia. HIE. Metabolic disturbances: (hypoglycemia, hypocalcemia , hypomagnesmia , hypo & hypernatremia). Inborn errors of Metabolism. Infections: congenital & acquired. Traumatic. cont. www.similima.com 16

    17. NEONATAL SEIZURES Aetiology: Structural abnormalities. Hemorrahge. Maternal drugs. www.similima.com 17

    18. NEONATAL SEIZURES Investigation: Glucose,Ca ,Mg . Urea&Electrolytes :Na+, K+, Ca+ Lumber puncture : CSF wbc?(viral,bacterial) Rbc’s ? Hmg. Ammonia level. www.similima.com 18

    19. NEONATAL SEIZURES Investigation: ABG-acidosis. Lactate/ Pyruvate ratio. Drug screen. Imaging: USG, CT, MRI. Karyotyping. EEG. www.similima.com 19

    20. Drug Therapy For Neonatal Seizures Standard Therapy AED Initial Dose Maintenance Dose Route Phenobarbital 20mg/kg 3 to 4 mg/kg per day lV, lM, PO Phenytoin 20 mg/kg 3 to 4 mg/kg per day lV, POª Fosphenytoin 20 mg/kg phenytoin 3 to 4 mg/kg per day lV, lM equivalents Lorazepam² 0.05 to 0.1 mg/kg Every 8 to 12 hours lV Diazepam²´ 0.25 mg/kg Every 6 to 8 hours lV AED= andtiepileptic drug; lV= intravenous; lM= intramuscular; PO= oral ªOral phenytoin is not well absorbed. ²Benzodiazepines typically not used for maintenance therapy. ³Lorazepam preferred over diazepam. www.similima.com 20

    21. Complications Cerebral palsy Hydrocephalus Epilepsy Spasticity Feeding difficulties www.similima.com 21

    22. MIASMATIC BACKGROUND OF SEIZURE Seizures comes in a mixed miasmatic state, it does not fall in a single group of miasmatic background. www.similima.com 22

    23. www.similima.com 23

    24. ABSINTHIUM www.similima.com 24

    25. CUPRUM MET www.similima.com 25

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