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Childhood Seizures in ER :

Management

By Dr. Hussein Abdeldayem, MD


Head & Professor of Pediatric Neurology Unit
Faculty of medicine, Alex University
Case
A 6 yr boy is
hospitalized because
of rhythmic shaking of
all limbs with eye
deviation
ER/Seizures
Seizure in children is one of the
most anxiety-provoking conditions
for parents and a coon reason for
emergency department visits,
especially if the seizure is of new-
onset or the child is not on anti-
epileptic medication
ER/Seizures (cont.)
Anti-epileptic drugs should not be routinely
initiated in the emergency department in
children whose seizures have resolved
Seizure ?

Epilepsy ?
Seizure
: the involuntary clinical manifestation (S &/or S)
due to an abnormal and excessive excitation
and synchronization of a population of cortical
neurons


Epilepsy
EPILEPSY

Number ??? Morethan


More thanone
one

More
Morethan
thanone
one
Time onset?? day
dayapart
apart

? FC, ? tetany unprovocative


unprovocative
ACUTE
Seizure is an
Manifestation

Chronic
Epilepsy is a
DISEASE
Is it Seizure?

What is the type of seizure?

How do u treat acute seizure?


PATHOGENESIS OF SEIZURES
Mechanisms of Seizures
Defective balance between excitatory and
inhibitory neurotransmission

+VE -VE
Mechanisms of Seizures
Defective balance between excitatory and
inhibitory neurotransmission

+
+VE -
-VE
classification
Aetiology
CP
EEG
EPILEPSY
Aetiology
1985 2010

Idiopathic Genetic

Symptomatic Structural (acquired)*


(Acquired)
Unknown
cryptogenic

* More in neonates and


infancts
Aetiology # Age
Before age 2: Developmental defects, birth
injuries, CNS infections and metabolic
disorders
Ages 2 to 14: Idiopathic (genetic) seizure*
disorders
Adults: Cerebral trauma, withdrawal,
genetic GTC
tumors, strokes, and unknown cause (in
50%)
Childhood Absence
The elderly: Tumors and strokes
General Activity

2-Classification accordingFocal Activity


to EEG findings
Classification according to EEG findings

Generalized Focal Focal with


2ry G
Both Cerebral Only a part of a
Hemispheres hemisphere
Loss of Consciousness No loss of
consciousness
MRI
Treated by Valproate Treated by
Carbamazipine
Pediatric Seizures
Seizure Type Classification

3- Clinically (ILAE 1981)


GENERALIZED FOCAL (PARTIAL)
1- Involves both cerebral 1- involve one
hemispheres hemisphere
2- Loss consciousness 2- NO Loss of consciousness
2- EEG: generalized
3- EEG: focal activity
3- no aura
4- aura

ASK
MRI

MRI
Partial
Partial(focal)
(focal)with
with
secondarygeneralization
secondary generalization
Which type of seizure is this ?

Generalized Seizures
Generalized Seizures

Tonic-clonic
Which type of seizure is this ?

Generalized Seizures
Generalized Seizures

Clonic
Which type of seizure is this ?

Generalized Seizures
Generalized Seizures

Tonic
Generalize Spike Wave
Discharge
Which type of seizure is this ?

Generalized
Generalized
Seizures
Seizures
Absence

VPA, ETX, LMT


Absence seizures and EEG
EEG: Absence Seizure

EEG: classic 3/sec spike-and-wave especially with HV


Which type of seizure is this ?

Generalized
Generalized
Seizures
Seizures

Myoclonic
Which type of seizure is this ?
Generalized
Generalized
Seizures
Seizures

Atonic
Generalized Seizures
Generalized Seizures

Tonic
Clonic
Tonic-clonic

VALPROIC
Absence
ACID
Myoclonic

Atonic

Mixed
Which type of seizure is this ?

(focal)
simple
Motor
EEG: Simple focal Seizure
EEG: Focal changes
Simple Partial (Focal) Seizures

Motor

Sensory

autonomic

psychic
Which type of seizure is this ?

Partial (Focal)

Complex partial

Complex Partial Seizure.flv


Partial (Focal) Seizures

Simple Complex 2ry Generalization

Carbamazepine
Febrile Convulsions FC
Definition
Age : between 6 months and <6 years of
age

with fever > 38 C ( rectal temperature)

but without evidence of intracranial


infection and no history of prior afebrile
convulsion
Precipitating factors:
1. Body
Precipitating factors:
Temperature:
Temperature 38
C

FC occur during 1st


24 hrs of the febrile
illness

Depends on the
rapidity of the rise
rather than the
temperature itself
2. Infections & FC:
VIRAL : UTRI, otitis media, roseola
infantum

Bacterial: gastoeneritis,
pneumonia, UTI

Post-Vaccinational: pertussis &


measles vaccination
3. Genetic Factors:
Positive family history for febrile seizures.

In most cases the disorder appears polygenic. I


n some families the disorder is inherited as an autosomal domina

Multiple single genes causing the disorder have


been identified, FEB 1, 2, 3, 4, 5, 6, and 7 genes on
chromosomes:
8q13-q21
19p13.3
2q24
5q14-q15
6q22-24
18p11.2
21q22.
Classification of FC
Simple (typical) FC

Complex (atypical) FC
Simple FC complex
FC
Constitute 80-85% of Constitute 15 20% of FCs
FCs
1- generalized tonic- 1-focal seizure manifestations
clonic motor activity
2- less than 15 minutes 2-prolonged seizure activity
with rapid return of exceeding 15 minutes
consciousness.
3- recurring more than once
3- not recurring more within 24 hrs
than once within 24hrs
4- postictal neurological
4-no postictal abnormalities
neurological
abnormalities
5- normal CNS child 5- abn CNS : as CP

NoEEG
No EEG EEG
EEG
NOAED
NO AED AED
AED
Which type of seizure is this ?

Infantile Spasms

ACTH

S Z aher IS.3gp
VPA
CZP
VGB
EEG finding:
hypsarrhythmias
NEONATAL CONVULSIONS
Subtle
1- APNEA 2- eye
NEONATAL CONVULSIONS
Subtle
3- oral
NEONATAL CONVULSIONS
Subtle
4- UL 5- LL
History (9)
First
Last
Frequency
Aura
Ictal
Postictal

duration
Investigation
Treatment
Practical Points

DURATION OF TREATMENT

2 years from last attack


Withdraw over 3 months
VPA GENERALIZED FITS

PARTIAL FITS
GENERALIZED FITS

CBZ PARTIAL FITS


Depakine
(Valproate)
20 60 mg/kg/d
Twice*
Forms
Oral with dropper
Oral with spoon
200 mg tablets
500 mg chrono tablets
Follow up of:
Serum drug level (peak)
Serum drug level (trough)
SGOT, SGPT, PT
Tegretol
(Carbamazepine)
10 20 mg/kg/d*
Twice
Forms
Oral (100 mg/5ml)
200 mg tablets
200 mg CR tablets
400 mg CR tablets
Follow up of:
Serum drug level (peak)
Serum drug level (trough)
Blood CBC
Question for ALL
For my pediatric epileptic patients, well
controlled seizures are mostly through:
A- Monotherapy
B Polytherapy (2 drugs)
C- Polytherapy (3 or more drugs)
D- Other methods (?)
Seizures in E D
Case
A 6 yr boy is hospitalized because of
rhythmic shaking of all limbs with eye
deviation
prolonged seizures may result in neuronal
injury, cell death, or both, and this
becomes most pronounced after half hour
or more of continuous seizure activity

the earlier the therapeutic intervention, the


more likely one can terminate the seizure
Status Epilepticus

30*** minutes of continuous seizure


without regaining consciousness

Two or more Seizures with Failure to


regain consciousness Between
Seizures (serial status)
Practical SE
If a seizure continues for more than 5
minutes
or
the patient has 2 or more generalized
tonic-clonic seizures within 1 hour,

Aggressive management is warranted as


these patients progress rapidly to status
epilepticus
Practical Status epilepticus
Generalized convulsive status epilepticus
involves at least one of the following:
Tonic-clonic seizure activity lasting > 5 to
10 min
2 seizures between which patients do
not fully regain consciousness
Handling
of the active
seizure

Stay calm and


manage effectively
Never restrain the child or place anything in the mouth
Treatment

ABCDs

Specific treatment*
ABCDs
Airway
Breathing
Circulation
Drugs

*Initial studies include glucose, serum chemistries (most importantly


sodium, magnesium, calcium, phosphate, BUN), arterial blood gas,
AED levels (if applicable), CBC
Lorazepam (ativan) 0.1 mg/kg

Diazepam 0.3 mg/kg*

PR diazepam 0.5 mg/kg


In infants less than 24 mo of age,
intravenous pyridoxine (100200 mg)
should be considered.
Rectal Diazepam*
The absorption of oral diazepam is slow
(1-2 hours) and variable.
Intramuscular diazepam has similar
absorption problems, is painful and may
cause muscle necrosis.
Suppositories have slow and variable
absorption rates and are not
recommended in an emergency.

Rectal administration of the intravenous form of diazepam


Rectal Diazepam*
Intravenous and rectal diazepam both stop
seizures in more than 80% of cases within
10-15 minutes

Less Resp Depression

Less BP Depression

Less CNS Depression

Prolonged action
Rectal Diazepam
Use IV ampoules (10mg/2ml) or gel
Use Insulin syringes*
Rectal administration (use lubricant)

Dose: 0.5 MG/KG max: 10 mg

Lubrication

Diazepam adsorbs to plastic and thus needs to be stored in glass


3
The following statements are
either true or false
Rectal diazepam is the treatment of choice
for status epilepticus. False

2. Oil in water emulsions of injectable


diazepam are inappropriate for rectal
administration. True
Timed treatment
0 5 min ABCD*
5 -10 min BZD IV x2
10-20 min DPH or PB IV
20-30 min PB or DPH IV
>30 min midazolam IV continuous
infusion**
4060 min ICU, anesthesia, EEG
Give the Diagnosis
Seizure pretenders

Paroxysmal nonepileptic disorders that


may be mistaken for seizures
include syncope, breath holding
spells, sleep disorders, migraine
headaches, apparent life threatening
events (ALTE), and pseudoseizures
Thank you
Case (cont.)
You are called to the bedside and after 5
minutes, these movements have not
stopped.
Options for your next course of action are:
1- continue to wait for the spell to subside
2- administration of IV diazepam
3- administration of IV phenytoin
4- administration of IV phenobarbitone