Seizures in Childhood

1. Seizures in Childhood CME November 2-4, 2013 Dr. Lumphoon

2. Pre-Test • What is the most common cause of childhood seizures? a) poisoning b) birth trauma c) fever d) head trauma

3. Pre-test 2) What drug should you use to stop a seizure that has lasted 4 minutes? a) phenobarbital b) diazepam c) phenytoin d) don’t treat unless seizure has lasted at least five minutes

4. Pre-test 3) When a child has a seizure, when is a lumbar puncture indicated? a) In every case b) Only if there are signs of increase intracranial pressure c) If there is fever and neck stiffness, and meningitis is being considered d) If the child has a red throat

5. Pre-test 4) What is the first thing you do when confronted by a seizing patient? a) ABC’s , recovery position, glucose b) Draw blood for electrolytes and glucose c) Administer bicarbonate to counteract metabolic acidosis d) Observe to see how long the seizure is going to last

6. Pre-test 5) What is the most important part of chronic seizure management in children? a) Use of two medications for seizure control b) Discovering the family’s knowledge level and educating them as much as possible about the seizures and what to do. c) CT scan of the brain d) Educate the community about the seizures e) b and d

7. Seizure Definition • Transient, paroxysmal, involuntary events characterized by alterations of consciousness, behavior, motor skills, autonomic activity, or sensation. • Results from abnormal, involuntary rhythmic discharges from a group of neurons in the brain. • A seizure is a sign of underlying disease, not a disease itself.

8. Status Epilepticus • Status epilepticus involves continuous seizure activity or intermittent seizure activity without full recovery for a period of 30 minutes or longer. • Status epilepticus is an emergency. • These seizures need to be stopped, and the etiology needs to be addressed to avoid neurological damage.

9. Epilepsy • The term ”epilepsy” refers to that state of susceptibility of a child or adult to recurrent seizures.

10. Case 1 • Noy is a 3- year old girl who presents to your clinic with a history of fever for two days. She now has had a seizure which first occurred this morning. • Noy is accompanied by her grandfather.

11. Case 1 • Noy is sleeping comfortably in grandfather’s lap and appears stable. • What questions do you need to ask her grandfather about the seizures?

12. Case 1 • WWQQAAAB • Where • When • Quantity • Quality • Aggravating factors • Alleviating factors • Associated factors • Belief about symptoms

13. Short differential • What is your short differential diagnosis?

14. Case 1 • What other relevant history do you request?

15. Case 1 • Past Medical History: Previous seizures, prematurity, prenatal, intrapartum or neonatal problems • Development: Past development, any regression. • Family History of seizures, epilepsy (higher occurrence of both with positive family Hx) • Social History: Why has her grandfather brought her? • Immunization status • Medication • Allergies • Pets, Travel • Review of Systems

16. Case 1 • Noy has been previously healthy. Normal development so far. Her grandfather doesn’t think she has had any immunizations yet. • One of Noy’s teenage sisters has had seizures intermittently since she was a 2 year old. • Noy lives with her grandfather because both her parents died “in an accident”. 

17. Case 1 • What is your problem list? • Is there any change to your differential diagnosis ? • May use VITAMIN CDP to generate a larger Differential Diagnosis.

18. Case 1 • Just as you prepare to do a physical exam, Noy stiffens in all limbs, her eyes roll back and she begins shaking rhythmically.

19. Case 1 • What do you think is happening? • What do you do?

20. Case 1 • It seems like Noy is having a seizure but you need to distinguish seizure from jitteriness or rigors/chills • You cannot stop a limb which is seizing by holding it (this trick is especially useful in neonates) • Level of consciousness will be impaired if this is a generalized tonic-clonic seizure

21. Case 1 • You have decided this is most likely a febrile seizure. • What do you do now?

22. DO • ABC’s-recovery position, put nothing in mouth unless it is for the airway, clear vomitus, jaw thrust if necessary. • O2 if needed (usually don’t need this, so it does not need to be a priority)

23. DO • Assess for shock / dehydration • Check glucose OR consider empiric dextrose- D50- treatment if no testing kit available

24. DO • Assess—don’t panic—only treat with medication if seizure lasts >5 min. • Note if there are any localizing features

25. You are once again prepared to do a physical exam. What are the most important things to do and document?

26. Physical exam • Vital signs, Head Circumference • Level of consciousness. • Pupils and Cranial Nerves for palsy. • Fundoscopy for papilledema (discuss risks associated with raised ICP). • Meningeal signs are critical. • Any focal neurological findings (need to document tone, reflexes, Babinski).

27. Physical exam • Pallor and cardiac gallop (malaria) • Petechiae (meningitis) • Spleen and liver enlarged?

28. Case 1 • Noy has a temperature of 40.2oC. HR 120. RR 28. You notice a II/VI systolic ejection murmur along the left sternal border. There is no gallop and she is not pale. •  She has not had another seizure • What do you think about the murmur?

29. Case 1 • Heart murmurs—this is most likely a benign flow murmur especially common in thin children with fevers (to be sure, you must check again when fever has gone down).

30. DDx • Prepare a differential diagnosis for seizures in a patient such as Noy based on what you know. • Comment on differentiating features.

31. Differential Diagnosis • Febrile convulsion secondary to infection (viral, bacterial or malaria) • Meningitis • Cerebral Malaria • Seizure secondary to hypoglycemia (and possibly malaria) • encephalitis, • trauma, • stroke/hemorrhage, • poisoning • metabolic encephalopathy, • neurodegenerative disorder, • brain tumor, neurocutaneoussyndrome

32. What is your problem list ?

33. Problem list • Acute febrile seizure • ? Infection—malaria vs meningitis vs other • Not immunized • Need for family counseling, what to do if siezure recurs • Heart murmur • Orphaned • Family history of non febrile seizure

34. Which investigations would you consider?

35. Investigations • Laboratory tests (such as CBC, Na+, K+, Ca++, Mg++, glucose, and P04) depend on the symptoms, seizure type, and history… if no history of fever, must consider electrolytes • If a seizing febrile child has had several episodes of vomiting and diarrhea, check electrolytes, just as if the child had seized without fever. • In the case of simple febrile seizures, routine laboratory tests are usually not indicated.

36. Investigations • The literature for tests for complex febrile seizures is not as clear as those for simple febrile seizures. • Do consider laboratory tests in children who present with complex febrile seizures. • A child with fever may also have a known seizure disorder, so check seizure medication levels.

37. Fever without an obvious source • Obtain a CBC and blood cultures • Catheterized urine for urinalysis and urine culture • Stool culture for bacterial or viral enteric infection, and shigellosis • Nasal swabs for respiratory syncytial virus (RSV) or influenza, if appropriate.

38. What about a lumbar puncture?

39. Indicators For Lumbar Puncture For Evaluation Of Pediatric Febrile Seizure • Recent doctor (or health care provider) visit for febrile illness • Less than 12 months of age* • 12 months to 18 months of age* • Altered mental status • Prolonged post-ictal period * If the child returns to normal (ie, normal neurological examination, appears happy, nontoxic, etc.) in a case where meningitis is considered unlikely, some literature suggests that an LP is not strongly indicated in the routine evaluation of a febrile seizure

40. Indicators For Lumbar Puncture For Evaluation Of Pediatric Febrile Seizure • Signs of increased intracranial pressure (ie, bulging fontanelle)-if considering meningitis • Kernig’s or Brudzinski’s sign • Increased irritability • Petechiae • Recurrent seizures, seizures in the Emerg Dept • Recent antibiotics

41. Case 1 • Prepare a brief treatment plan based on your problem list

42. Case 1 • Airway • Breathing (O2 if necessary) • IV access for hydration, • Antipyretic: acetominophen • Bloodwork (glucose, Na, K, CBC, blood cultures, urinalysis, urine culture) • Antibiotic (+/- steroids) • + / - LP • ? Antimalarials

43. Noy recovers thanks to your fine management • Discuss what information you will give her grandfather : chance of recurrence, what to do at home, when to bring her to hospital again

44. Facts: Febrile Seizures • 3mo - 5yr • Single, brief, occurs during rapid rise of fever >38C, but without evidence of intracranial infection or defined cause • Generalized seizure / Not focal • Normal child neurologically both before and after seizure

45. Facts: Febrile Seizures • Called “complex” febrile seizure if lasts longer than 15min, is focal, or recurs within 24h (although this seems common with malaria) • Complex seizures have an increased risk of meningitis (9%), compared to simple febrile seizure (3%) • Many children will have a positive family history of febrile seizure and recurrence is high (about 1/3)

46. Facts: Febrile Seizures • There is no strong evidence that giving antipyretics in the absence of Anti Epilepsy Drugs (AED) can prevent recurrent febrile seizures. • AEDs are not routinely recommended for the chronic prevention of febrile seizures.

47. Facts: Febrile Seizures • Children with febrile seizures have only a 1-2% chance of developing lifetime epilepsy, compared to only a 0.5 - 1% risk in other children • Unless there are 2 or more risk factors (such as family history of epilepsy, neurological condition or disorder, or complex seizure), then the risk for epilepsy jumps to 10%

48. Facts: Febrile Seizures • 33% of children who experience a febrile seizure will experience a second febrile seizure • Peak incidence of febrile seizures occurs at about 18 months of age

49. Case 2 • A 4-year old boy is brought to see you by his parents. 5 minutes ago he started having a generalized tonic- clonic seizure. There was no preceding trauma. Prior to the seizure, the parents describe that the boy was vomiting and was talking funny.

50. Case 2 • On exam the boy is having a generalized tonic clonic seizure. He is not responding to verbal or painful stimulation. • HR 140, BP 70/40, RR 20, O2 sats 96%. His temperature is 37.8C. • His pupils are dilated bilaterally and reactive to light. He is hyper-reflexic. Normal cardiovascular, respiratory and abdominal exam.