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    The_seizing_child.ppt The_seizing_child.ppt Presentation Transcript

    • Pediatric Seizures Muhammad Waseem, MD Emergency Medicine Lincoln Hospital
    • Few things are more frightening to parents than to witness their child having a seizure
    • Objectives
      • Wide spectrum of Pediatric seizure
      • Etiologies specific to children
      • Treatment modalities in children
      • Quality of life issues
      • Legal implications
    • Seizure
      • Common neurologic disorder
      • 3 - 5% of children
      • 1/2 classified as febrile seizures
      • Epilepsy (0.5 - 1%)
    • Seizure
      • 10% ambulance calls for children
      • 1.5% of total ED visit
      • Most resolve in the pre-hospital setting
    • Seizure - ED visits
      • Febrile seizure 53%
      • Established epilepsy 31%
      • New-onset seizure 10%
      • Status epilepticus 5%
    • Causes
      • Idiopathic 76%
      • Developmental 13%
      • Infection 5%
      • Head trauma 3%
      • Other 2%
    • Seizure
      • Fit
      • Spell
      • Attack
      • Convulsion
    • What is Seizure?
    • Seizure
      • Paroxysmal, time-limited event that results from abnormal neuronal activity in the brain
      • Paroxysmal alteration in neurologic function (i.e, behavioral, motor, or autonomic function, or all three - volpe 1989.
    • Convulsion
      • A seizure with prominent motor manifestation
    • Epilepsy
      • Disorder of CNS whose symptoms are seizures
      • Recurrent seizures
      • Unprovoked
    • Seizure
      • Most seizures are not epileptic
      • Non-epileptic seizures are physiologic
        • Hypoxia
        • Fever
        • Toxins
    • Seizure
      • Seizure is a symptom of a disorder that need further investigations
      • Does not constitute a diagnosis
      • May occur in both normal & abnormal tissue
    • Non-epileptic Events
    • Mimic Seizures
      • Breath-holding spells
      • Syncope
      • Migraine
      • Tics
      • Night terror
      • Pseudo-seizures
    • Non-epileptic Events
      • Inaccurate diagnoses
      • Inappropriate use of AED
    • Non-epileptic Events Careful history
    • Breath-holding spells
      • Frightening
      • 6 months - 4 years
      • Inciting event-Shrill cry-Breath holding-Cyanosis
      • Disappear spontaneously before school age
    • Night Terrors
      • 5 - 7 years
      • Between midnight and 2 AM
      • Slow wave sleep stage 3 or 4
      • Frightened and screaming
      • Increased autonomic activity
      • Sleep follows in few minutes
      • No recall
    • Pseudo-seizure
      • Diagnosis of exclusion
      • 10 - 18 years
      • Bizarre, unusual postures
      • Verbalization
      • Uncharacteristic movements
      • Can be persuaded to have an attack on request
    • Pseudo-seizure
      • Lack of cyanosis
      • Talking during seizure
      • Normal reaction to pupil
      • No loss of sphincter control
      • Normal plantar responses
      • Lack of post-ictal drowsiness
      • Poor response to AED
    • Seizure
      • First step in identifying the epileptic syndrome is correctly identifying the type of seizure
    • Why Should I know type of Seizure?
    • Seizure
      • Clue to cause
      • Appropriate treatment
      • Prognosis
    • Epileptic Seizures
      • Partial (40%)
      • Generalized
      • Unclassified
    • Partial Seizure
      • Simple Partial
      • Complex Partial
      • Partial with secondary generalization
    • Generalized
      • Convulsive
      • Non convulsive
        • Absence Seizure
    • Generalized- Convulsive
      • Myoclonic
      • Clonic
      • Tonic
      • Tonic-clonic
      • Atonic
    • Simple Partial Seizures (SPS)
      • Consciousness not altered
      • Aura
      • Motor activity (face, neck or extremity)
      • “ Feeling funny” or “ something crawling inside me”
      • No post-ictal phenomenon
    • Complex Partial Seizures (CPS)
      • Impairment of consciousness
      • Aura
      • Brief blank stare or sudden cessation or pause in activity
      • Automatism (lip smacking, chewing, swallowing and excessive salivation)
    • Complex Partial Seizures (CPS)
      • Dystonic posturing, tonic or clonic movement
      • Postictal phase
      • Duration 1 - 2 minutes
      • Usually during waking hours
    • Absence Seizure
      • Sudden cessation of motor activity or speech
      • Blank facial expression
      • Flickering of eye lids
    • Absence Seizure
      • Uncommon before age 5 year
      • Girls
      • No Aura
      • No postictal state
      • Rarely persist longer than 30 sec
    • Absence Seizure
      • Hyperventilation induces an absence seizure
      • 3/sec spike on EEG
    • Myoclonic
      • Quick muscle jerks
      • Loss of body tone
      • Consciousness usually unimpaired
      • Specific epilepsy syndromes
    • Tonic
      • Tonic spasms of truncal & facial muscles
      • Flexion of upper extremities
      • Extension of lower extremities
    • Clonic
      • Resembles myoclonus
      • Loss of consciousness
      • Slower
    • Tonic-clonic
      • Extremely common
      • Begins suddenly without warning
      • Tonic contraction of the trunk
      • Rhythmic clonic contraction alternating with relaxation of all muscle groups
      • Marked increase in HR and BP
      • incontinence
    • Tonic-clonic
      • Seizure last 1 to 2 minutes
      • Post-ictal 30 minutes to 2 hours
    • Atonic Seizures
      • Suddenly dropping to the floor
      • Lanox-Gastaut syndrome
      • Can occur without LOC
    • Case 1
    • Case 1
      • 9-year-old boy
      • Parents were aroused one night by noise from his bed room
      • Noted bed sheets awry & breathing deeply
      • bitten his tongue
    • Case 1
      • Confused
      • Afebrile
    • First Non-Febrile Seizure
    • History
      • Was this a true seizure or a non-epileptic event?
    • History
      • Circumstances
        • Normal activity vs. provoked
        • Upon awakening
      • Duration
      • Aura
      • Abnormal motor movements
      • Abnormal eye movements/automatism
    • History
      • Post-ictal period
      • Urinary or fecal incontinence
      • Fever, trauma or drug
      • Birth history
      • Delayed milestones
      • Family history of seizures
    • Physical Examination
      • Vital signs
      • Level of consciousness
      • Head circumference (percentile)
    • Always undress and examine the child
    • Café-au-lait spot
      • Uniformly hyper-pigmented
      • sharply demarcated macules
      • Normal children (1-3 spots)
      • 10% of normal children
      • May be present at birth or develop later
    • Neurofibromatosis (NF-1)
      • Six or more, >5 mm in prepubertal
      • Six or more, >15 mm in postpubertal
      • Crowe sign
        • freckled appearnace in axilla
    • Neurofibromatosis (NF-1)
      • Present in 100% of patients
      • present at birth
      • Increase in size, number & pigmentation
      • Predilection for trunk & extremities
      • Spare face
    • Lisch nodules
      • Pigmented hamartomas of the iris
      • NF-1
      • Prevalence increases with age
        • 5% (<3 years)
        • 42% (3-4 years)
        • 100% (21 years)
    • Lisch nodules
      • Asymptomatic
      • Do not correlate with the extent & severity
      • Do not occur in normal individuals
      • Best identified with slit lamp
    • Adenoma Sebaceum
      • Erythematous papules over nose & malar areas
      • Develop between 4 and 6 years of age
      • coalesce & assume fleshy appearance
      • Tuberous sclerosis
    • Ash-leaf spots
      • Hypo-pigmented
      • Irregular borders
      • May be present at birth
      • Detectable by 2 years in 50%
      • Wood’s ultraviolet lamp
    • Shagreen patch
      • Roughened raised lesion
      • Orange-peel consistency
      • Primarily lumbo-sacral area
    • Tuberous Sclerosis
      • Infantile spasm
      • Hypsarrhythmic EEG pattern
    • CT Scan
      • Periventricular calcifications
    • MRI
      • Multiple cortical tubers
    • Port-wine stain
      • Macular cutaneous nevus
      • Present at birth
      • Always involves upper face & eye lids
      • unilateral
      • Sturge-Weber Disease
    • Port-wine stain
      • Tonic clonic seizure contralateral to the side of facial nevus
      • Refractory to anticonvulsant
      • hemiparesis
    • CT Scan
      • Normal at birth
      • Gyriform contrast enhancement
      • Hemispheric atrophy
      • Parenchymal calcification
        • Railroad track
    • Physical Examination
      • Café-au-lait spots (NF)
      • Adenoma sebaceum (TS)
      • Facial hemangioma (Sturge-Weber)
      • Petechiae (meningitis)
    • Physical Examination
      • Hematoma or skull fractures
      • Signs of raised ICP
      • Retinal hemorrhages (Child abuse)
      • Signs of meningeal irritation
    • Diagnostic Evaluation
      • Bedside glucose
      • Serum Ca & Mg (< 3 months old)
      • Urine drug screen
      • CT head
      • Outpatient EEG
    • Rolandic Epilepsy Benign Partial Epilepsy with Centrotemporal Spikes (BPEC)
    • Rolandic Epilepsy
      • Common in childhood
      • 2 - 14 years
      • Peak age 9 -10 years
      • Normal children
      • Unremarkable past history
      • Normal neurologic examination
    • Rolandic Epilepsy
      • Simple partial seizure
      • 3-13 years (peak 9-10 years)
      • Almost always at night (75% sleep)
      • EEG (centrotemporal spike)
      • Carbamazepine
      • Excellent prognosis
      • Spontaneous remission by age 15 year
    • Infantile Spasm (West’s synd)
      • Sudden jerks of group of muscles
      • 4-12 months
      • Characteristic EEG (hypsarrhythmia)
      • Poor prognosis
      • ACTH/Steroid
    • Case 2
    • Case 2
      • 7-month-old boy with runny nose and fever. His pediatrician saw him & diagnosed URI. He received tylenol. On the same afternoon while sitting on his mother’s lap he began to stare and had a generalized tonic-clonic seizure. The entire episode lasted approx 5 minutes
    • Case 2
      • He fell asleep after the seizure.
      • Normal development
      • T 102 F, HR 124, R 30 BP 90/50
      • Wt 7.9 Kg (50%)
      • Ht 66.5 cm (50%)
      • HC 44 cm (50%)
      • No NC lesions
    • Febrile Seizures
    • Febrile seizures
      • Most common type of seizures in the pediatric age
      • usually benign
      • Can cause considerable parental anxiety
    • Febrile seizures
      • Seizures that occur in infancy or childhood usually occurring between 3 months and five years, associated with fever, but without evidence of intracranial infection or defined cause
    • Febrile Seizures
      • Age dependent
      • Rare before 9 months & after 5 years
      • Peak age 9-20 months
      • Incidence 3 - 4%
      • Family history
      • Diagnosis of exclusion
    • Febrile Seizures
      • Risk factors
        • Height of temperature
        • Male sex
        • Family history of febrile seizure
    • Febrile Seizures
      • A family history of epilepsy has not been shown to be a risk factor for first febrile seizures
    • Febrile Seizures
      • Risk factors for recurrence
        • Young age at onset
        • Febrile seizures in first degree relative
        • Lower degree of fever
    • Febrile Seizures
      • Generalized tonic-clonic
      • Duration few seconds to 10 minutes
      • Excellent prognosis
      • 20% are complex
    • Febrile Seizures
      • Complex febrile seizure
        • > 15 minutes
        • More than once in 24 hours
        • Focal neurologic features
    • Febrile Seizures
      • Risk of recurrence 34%
      • Most recurrences within 6-12 months
    • Lumbar Puncture
      • The decision to perform LP should be based on the age of the child at presentation (AAP)
    • Lumbar Puncture
      • < 12 months
        • Strongly recommend
      • 12 - 18 months
        • Should consider
      • > 18 months
        • If history & physical examination suggest intracranial infection
    • Febrile Seizures
      • Signs of meningeal irritation
        • Unreliable under 18 months
    • Red flags
      • Focal seizure
      • Suspicious physical examination findings (eg, rash, petechiae) cyanosis, hypotension, or grunting
      • Abnormal neurologic examination
    • Febrile Seizures
      • Meningitis must be ruled out
        • Difficult if the patient is on antibiotics
    • Febrile Seizures
      • Determine and treat the cause of fever
      • IV benzodiazepine
      • Rectal diazepam
      • No routine AED prophylaxis
    • Febrile Seizures
      • Incidence of epilepsy
        • 1% (No other risk factor)
        • 9% (Other risk factors)
    • Epilepsy
      • Family history of later epilepsy
      • Preexisting neurologic abnormality
      • Complex febrile seizure
        • > 15 minutes duration
        • > 1 febrile seizure per 24 hour
      • Focal febrile seizure
    • Neonatal Seizures
    • Neonatal Seizures
      • Seizures during first 28 days
      • 0.5% of all live births
      • Do not indicate epilepsy
    • Jitteriness Vs Seizure
      • Movements are stimulus sensitive
      • Appear during active state (crying)
      • Disappear on passive flexion
      • Not jerky
      • No abnormal eye movements
    • Neonatal Seizures
      • Neonates are at particular risk
        • Metabolic
        • Toxic
        • Structural
        • Infectious
    • Neonatal Seizures
      • Not generalized tonic-clonic
        • incomplete myelination
      • Can be very subtle
      • Minimal physical findings
    • Neonatal Seizures
      • Subtle
      • Tonic
      • Clonic
      • Myoclonic
    • Subtle Seizure
      • More common in premature infants
      • Eye deviation + jerking
      • eyelid blinking
      • fluttering
      • smacking or drooling
      • Apneic spells
    • Causes
      • Perinatal asphyxia
      • Intracranial hemorrhage
      • Metabolic - hypoglycemia, hypocalcemia
      • Infections
      • Drug withdrawl
    • History
      • Family history
        • metabolic
      • Maternal drug history
      • Delivery
        • Mode & nature of delivery
        • Fetal intrapartum status
        • Resuscitative measures
    • Physical Examination
      • Gestational age
      • Blood pressure
      • Presence of skin lesions
      • Presence of hepatosplenomegaly
      • Neurologic evaluation
    • Lab
      • Serum chemistry
      • Spinal fluid
      • Metabolic work-up
        • serum ammonia
        • amino-acids
    • Lab
      • Head sonogram
        • IVH/periventricular
      • CT head
        • Hemorrhage
        • Calcifications
        • Malformations
      • EEG
    • Management
      • The method of treatment depends on the cause
      • Anticonvulsant
        • Phenobarbital
    • Status Epilepticus
    • Status Epilepticus
      • Seizure >30 minutes
      • Intermittent seizures longer than 30 minutes from which the patient does not regain consciousness
    • Status Epilepticus (SE)
      • Highest incidence in very young children
      • 5% of ED visit of seizing children
      • 70% of children with epilepsy experience at least one episode of SE
      • Mortality rate 8 to 32%
    • Status Epilepticus (SE)
      • Any type of seizure
      • Generalized (most common)
      • Absence or partial (10%)
      • Febrile SE (25%)
    • Life-threatening causes
      • Bacterial meningitis
      • Hypoglycemia
      • Increased intra-cranial pressure
      • Hypoxemia
      • Toxins
        • TCA, Cocaine, Theophylline, insulin
    • Management
      • Rapid stabilization of cardio-respiratory functions
      • Termination of both clinical & electrical seizures
      • Diagnosis & treatment of life threatening precipitant
    • Status Epilepticus
      • “ The child is often given too much IV benzodiazepine….Blood gases are measured and perhaps the values are found to be slightly decreased. The child is then paralyzed, intubated, and sent to the intensive care unit to recover from the iatrogenic morbidity.”
    • Status Epilepticus
      • Freeman JM: Status epilepticus: It’s not what we’ve thought or taught. Pediatrics 1989;83:444-445
    • Status Epilepticus
      • Primary goal is to stop the seizure
      • First line (benzodiazepine)
      • Second line (phenytoin or fosphenytoin)
    • Diazepam
      • Rapid onset (3 - 5 minutes)
      • Orally, IV, IM, IO or Rectal
      • Duration of action 20 - 30 minutes
      • Respiratory depression, sedation, hypotension
      • Diastat (rectal gel)
    • Diazepam
      • IV 0.1 - 0.5 mg/kg
      • Rectal 0.2 - 2 mg/kg (maximum 10 mg)
    • Lorazepam
      • Slower onset
      • Longer duration (12 - 24 hours)
      • Orally & IV
      • Inappropriate for rectal administration
      • 0.05 - 0.2 mg/kg
      • “ Must be refrigerated”
      • Tachyphylaxis
    • Phenobarbital
      • Long duration (24 hours)
      • IV 10-20 mg/kg bolus rate 1-2 mg/kg/min
      • Intubation (>30-40 mg/kg)
      • Respiratory depression, hypotension & bradycardia
    • Phenytoin
      • 1950 - Massachusetts General Hospital pH 12, limited solubility in water Propylene glycol & ethanol
      • 1956 - Parenteral formulation approved
      • 1962 - pediatric dose recommendation
      • 1986 - Revised Pediatric dose (15-20 mg/kg, 1-3 mg/kg/min)
    • Phenytoin
      • High pH
        • Burning & cutaneous reactions
        • Purple glove syndrome
    • Phenytoin
      • Propylene glycol
        • Seizures
        • Arrhythmia
        • Asystole
        • Hepatic & renal damage
        • Hemolysis
        • Hyperosmolality
        • Lactic acidosis
    • Phenytoin
      • The amount of propylene glycol in a typical loading dose of phenytoin administered to a 1 kg premature neonate is about seven times greater than WHO standard
    • Fosphenytoin 1996
      • Pro-drug of phenytoin
      • pH 8
      • Far more soluble in water
      • No organic solvent
      • Both IV & IM
      • Rapid & complete conversion to phenytoin
    • Sports Participation
    • Sports Participation
      • Unnecessary restrictions
      • Successful athelete with epilepsy
        • Gary Howatt (hockey player)
    • Sports Participation
      • Which sport
      • “Common sense”
      • Significant metabolic imbalance
        • Scuba diving
      • Potential for serious injury
    • AMA Committee for Sports
      • “ Patients with epilepsy will not be affected by indulging in any sport, including football, provided the normal safegaurds for sports participation are followed, including adequate head protection”
    • Permitted Sports
      • Baseball
      • basketball
      • broad jumping
      • hockey
      • gymnastic
      • Soccer
      • wrestling
    • Reasonable precautions
      • Bicycling
      • Diving
      • Football
      • Skating
      • Swimming
    • Prohibited Sports
      • Boxing
      • Bungee jumping
      • Polo
      • Scuba diving
      • Skydiving
      • Waterskiing
    • Driving & Regulatory Issues
    • Driver Licensing
      • Each state has its own regulations
      • “Seizure free period”
        • 1 Year (NY)
    • Reporting responsibility
      • Patient responsibility (most states)
      • Physician responsibility (Six states)
        • CA, DE, NE NJ, OR, PA
    • Employment
    • Employment
      • Average intelligence
      • Good health
      • Unpredictable loss of consciousness
    • Employment
      • No hard-and-fast rules
      • Should avoid workplaces in which a sudden loss of consciousness may expose them or their coworkers to risk or injury
    • Employment
      • Interstate truck
      • Forklift
      • Working in heights
    • Pregnancy & Epilepsy
    • Pregnancy & Epilepsy
      • 20,000 births women with epilepsy
      • Lower seizure threshold
    • Offspring & AED
    • Offspring & AED
      • Pheytoin
        • fetal hydantoin syndrome
      • Valproate
        • neural tube defect
      • Carbamazepine
        • spina bifida
    • Labor & Delivery
    • Labor & Delivery
      • Bleeding tendency in neonate
        • induction of hepatic enzymes
        • overcome by Vitamin K
    • Breast feeding & AED
    • Breast feeding & AED
      • Nearly all epileptic drugs are transferred in breast milk
      • Phenytoin 18%
      • Phenobarbital 36%
      • Carbamazepine 41%
      • Valproate 5%
      • Breast feeding is not contraindicated
    • Oral contraceptives & AED
    • Oral contraceptives & AED
      • Increase the dose of Oral contraceptives (AED induces hepatic metabolism of hormones)
    • Don’t forget child abuse Discrepancy between history & injury
    • “You are mandated by law to protect these children”
    • It’s not optional
      • New York State Law (Social Services Law Section 413) requires that any health professional who suspects that a child is being endangered or maltreated must report his/her suspicion to NY City, to the local child protection services
    • New AED’s
    • New AED’s
      • Gabapentin (Neurontin)
      • Lamotrigine (Lamictal)
      • Vigabatrin (Sabril)
      • Felbamate (Felbatol)
    • Take home message
      • Wide range of presentation
      • Efficiently obtain information
      • Always undress & examine
      • Establish underlying etiology
      • Suspect abuse with inconsistent history