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Seizures

Seizures. Julie Jaffray, MD Emily Pollakowski, MD. What are Seizures. Transient Involuntary Alteration in consciousness, behavior, motor activity, sensation or autonomic function Due to abnormal electrical neuronal discharge in cerebral cortex

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Seizures

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  1. Seizures Julie Jaffray, MD Emily Pollakowski, MD

  2. What are Seizures • Transient • Involuntary • Alteration in consciousness, behavior, motor activity, sensation or autonomic function • Due to abnormal electrical neuronal discharge in cerebral cortex • Signs and symptoms depend on location of discharge

  3. Types of Seizures • Febrile • Partial • Simple partial • Complex partial • Generalized • Absence • Myoclonic (muscle twitching) • Clonic (rhythmic shaking) • Tonic (rigid contracture) • Atonic • Tonic-clonic

  4. Febrile Seizures • Seizure occurring in childhood after one month of age, associated with a febrile illness not caused by an infection of the central nervous system • No previous neonatal seizure or previous unprovoked seizures • Vast majority are benign and rarely cause brain damage • Usually due to a rapid rise in temperature

  5. Febrile Seizures • 90% of febrile seizures occur between 6 months and 3 yrs of age • 2-5% children will have a febrile seizure at some point • Simple febrile seizures (70-75%) • Single, brief (<15min) generalized seizure during fever without intracranial infection or other causes and self resolves • Complex febrile seizures • Lasts >15 min, focal, reoccurs within 24 hours

  6. Simple Partial Seizures • Onset of seizure in a limited area, or one cerebral hemisphere • No impairment of consciousness • Highest incidence after 1 year of life • Risk of reoccurrence is higher than with generalized seizures • Can be sensory, motor or autonomic • Any structural lesion can causes SPS • Vascular, meningitis/encephalitis, trauma, tumors, hypoxic insult, postsurgical changes, metabolic/electrolyte shifts, endocrine disorders, meds/toxins

  7. Complex Partial Seizure • Starts focally within the brain then causes impairment of consciousness • Most commonly a manifestation of temporal lobe epilepsy • Typically last 30 sec-2 mins • Patient can describe an aura • Can be autonomic, simple motor, complex motor, negative (aphasic, atonic, hypomotor)

  8. Absence Seizures • Type of generalized seizure-not conscious • Brief, usually frequent throughout the day (in childhood absence) • Appear later in childhood • Staring spells, decline in school performance • Hyperventilation can provoke a seizure

  9. Tonic-Clonic Seizures • Occurs in several epilepsy syndromes • Initiated by 3 mechanisms • Abnormal response of a hyperexcitable cortex • Primary subcortical trigger • Abnormal innervation from subcortical structures • May have a prodrome hours to days prior to seizure • Mood changes, light headedness, anxiety, sleep disturbance, difficulty with concentration • Postictal state • Variable period of consciousness, gradually wakens usually confused

  10. Status Epilepticus • Any continuing type of seizure, but usually refers to a generalized convulsive state • Seizure lasting more than 30 mins • Continuous or multiple seizures without gaining consciousness • Can lead to hypertension, tachycardia, cardiac arrhthmias and hyperglycemia • Mortality is 20%

  11. Other Seizure Disorders • Neonatal seizure • Can be tonic, clonic, myoclonic or subtle (blinking, chewing, bicycling, apnea-due to immature CNS) • Usually a symptom of acute brain disorder • Hypoxic-ischemic encephalopathy • Intracranial hemorrhage/infarction • CNS infection • CNS malformation • Metabolic (hypoglycemia, hypocalcemia, toxins) • Inborn errors of metabolism • Infantile Spasms • Head nodding and flexion or extension of trunk and extremities • Often in clusters • Onset 2 months, peak 4-6 months

  12. Causes to think about • Intracranial infection (meningitis, encephalitis) • Intracranial tumor (benign or malignant) • Injury causing intracranial hemorrhage • Metabolic disturbances (hypoglycemia)

  13. Acute Seizure Management • Status Epileptus • Defined as > 30 minutes of continuous seizure activity or 2 or more sequential seizures in 30 minutes without full recovery of consciousness between seizures • Prepare for status with every seizure you witness -Medication dosing -Differential diagnosis

  14. Acute Seizure Management,Minutes 0-5 • Before anything else…A B C! • Airway • Breathing • Circulation • Stabilize patient • Establish access and obtain labs

  15. ABCs • Airway -Appropriate positioning -Open airway, using head-tilt/chin-lift -If suspected head/Cspine trauma, jaw thrust -Rule out obstruction

  16. ABCs • Breathing -Evaluate air exchange -Look and listen -Abnormal chest wall dynamics -If actively seizing: oxygen -If hypoventilating: ambu bag ventilation -Concern for aspiration

  17. ABCs • Circulation -Rate Goal HR >100bpm (infant), >60bpm (child) -Rhythm -Assess pulses (central and peripheral) -Assess capillary refill -IV access, send off labs

  18. Acute Management,Minutes 5-15 • Diazepam 0.5mg/kg IV/PR (max 6-10mg) • Check FSBS (if possible) • D10 bolus, 5mls/kg -use 20ml syringe: 4ml D50 + 16ml NS -repeat for full weight-based dose • Repeat diazepam if still seizing 5-10 minutes later • Think about next step

  19. Acute Management, Minutes 15-35 • Phenobarbital • Loading dose: 15-20mg/kg IV, then 5mg/kg q 30 minutes to max 30mg/kg • Maintenance: 5mg/kg/day IV, either BID or daily • Phenytoin/Fosphenytoin • Loading dose: 15-20mg/kg IV • Maintenance: 5mg/kg/day IV, divided BID, may increased to 8mg/kg/day

  20. Watch out! • Important to monitor closely during administration of above medications • Vitals (RR, HR, BP) • Level of consciousness

  21. Side Effects • Diazepam -Respiratory depression -Hypotension • Phenobarbital -Respiratory depression -Hypotension • Phenytoin -Hypotension -Arrythmias

  22. Overall Goals • Stabilize the patient • Stop the seizure • Determine etiology (labs, imaging) • Eliminate precipitating factors • Reverse correctable causes • Observe • Determine long term plan and need for daily AED

  23. Long Term Management • Too many drugs to remember! • Choice of AED depends on seizure type • Start with monotherapy, as 75% children with epilepsy will be, fully controlled • Polypharmacy is more expensive, decreases compliance, increases risk of toxicity

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