DEFINITION OF SEIZURE
A seizure (convulsion) is defined as a paroxysmal
involuntary disturbance of brain function that may
be manifested as
an impairment of loss of consciousness,
abnormal motor activity,
sensory disturbances, or
Epilepsy is defined as recurrent seizures unrelated to
fever or to an acute cerebral insult.
Seizures are common neurologic problem in
Seizures occur in 3-5 % of children.
Approximately 0.5-1.0% of children have
About 60% of all cases of epilepsy start in
In about half of all children with recurrent
seizures, the workup will not disclose a
There are many causes of epilepsy.
In general, any event having the potential to
produce insult to the brain can result in epilepsy.
Mostly the cause is a static or non-progressive
encephalopathy secondary to
hypoxia, hemorrhage, CNS infection, head
trauma, or developmental defects of the brain.
Labor and delivery complications are also less common
cause of epilepsy.
Other important entities to be considered are tuberous
sclerosis, neurofibromatosis, brain tumors, some inborn
errors of metabolism, and certain degenerative brain
The chance of having a second seizure after an initial
unprovoked episode is 30%.
The recurrence rate after the withdrawal of drugs is about
Grand mal epilepsy
Epilepsy is a clinical, not a laboratory diagnosis.
Age of onset of first seizure.
Duration and frequency of seizures.
Factors that may have precipitated the
seizures (e.g., fever.)
Seizures either focal or generalized in
Presence of aura.
Postictal confusion, sleep, or (Todd)
paralysis (on one side implies a focal
Any developmental delay.
Previous drug treatment for epilepsy or for
Exclude some organic cause.
Take head circumference.
Observe the facial (dysmorphic) features.
Complete CNS examination for any focal
Birthmarks such as café-au-lait spots or
hypopigmented macules may point to a
Fundoscopy for papilledema, chorioretinitis, retinal
hamartomas, and other congenital anomalies.
MANAGEMENT OF EPILEPSY
Principles of anticonvulsant therapy
Treat with the drug appropriate to the clinical type of
Do not use the anticonvulsant drug used previously without
Start with the one drug of choice in appropriate dosage.
Increase the dose until seizures are well controlled or signs
of toxicity appear.
If seizures are not controlled with one drug of
choice, second drug of choice is added. Do not stop
first drug suddenly. Withdraw it gradually.
Advise the parents and the patient that the therapy
will be prolonged but it will not produce any mental
slowing. Changes in medications or their dosages
should not be made without the advice of the
physician. Sudden withdrawl of anticonvulsants
may precipitate the seizures or even status
Follow up of the patient and periodic neurologic re-
evaluation is important.
If signs of toxicity appear, then reduce the drug by 25 %
or add another drug.
Get frequent blood levels of anticonvulsant drugs as
After 2 -3 years of fits free interval, consider withdrawl of
the anticonvulsant drug. Withdrawl should be gradual. In
about 75 % of cases, seizures may not recur. If seizures
recur during or after withdrawl, anticonvulsant therapy
should be reinstituted and again maintained for at least 2
or more years. Generally, an EEG is indicated before
withdrawl of an anticonvulsant. In case of an abnormal
EEG, withdrawl may be deferred for 2 — 3 years.
DETERMINATION OF BLOOD LEVELS OF
Other drugs may affect blood levels of anticonvulsants. In
such cases, adjustment of doses may be required.
Drug blood levels are indicated in a new patient, after a
new drug is introduced, when expected control on a
usual dosage has not been achieved, when seizures
recur in a previously well-controlled patient, or when
control is poor in a patient taking anticonvulsants being
seen for the first time.
A low level may indicate inadequate dosage, drug
interaction, or noncompliance with the prescribed
A high level may indicate slowed metabolism or excretion
or drug interaction.
EDUCATION ABOUT THE DISEASE
The patient and parents must be helped to
understand the problem of seizures and their
Materials about epilepsy must be provided.
Advise that the child should be very careful in cycling on
the road, unsupervised swimming, or locking the door of
the bathroom when inside.
Encourage normal living but within reasonable bounds.
Physical activities appropriate to their age should be
Loss of sleep should be avoided and emotional
disturbances may need to be treated.
Proper attention should be given to infections and it is
advised not to stop anticonvulsants in fever or in any
ACTH AND CORTICOSTEROIDS
These are indicated in infantile spasms and in
ACTH or oral corticosteroids are usually
continued in full doses for 2 weeks to 2 months
and after normalization of EEG and cessation of
clinical seizures, tapered over 1 week.
Dose of ACTH gel is 2 - 4 units/kg/day IM
in a single morning dose.
Prednisolone is given 2-4 mg/kg/day orally in two
or three divided doses.
KETOGENIC OR MEDIUM-CHAIN
A ketogenic diet should be recommended in
myoclonic and absence seizures not responding to
drug therapy. It is occasionally recommendd for
inflantile spasms that do not respond to ACTH or
Ketosis induced by ktogenic diet raises the seizure
Seizures with primarily focal origin, neurosurgery
should be considered for poorly controlled seizures.
It is defined as a single generalized or
series of tonic convulsions lasting 30
minutes or longer without intervening return
of consciousness OR an epileptic seizure
which is so prolonged or so frequently
repeated as to create a fixed and lasting
There are two types of status epilepticus:
convulsive and non-convulsive. The latter
consists of prolonged absence or complex
It is estimated that 1.3-16% of all patients with
epilepsy will develop status epilepticus at some
point in their lives.
In some patients, it is the presenting initial seizure.
Status epilepticus occurs most frequently in
patients younger than 1 year of age.
The etiology differs according to the age group. Two
common causes are withdrawal of anti-epileptic
drugs and hyperpyrexia secondary to a non-CNS
infection in a patient with chronic static
encephalopathy or seizure disorder.
Brain damage occurs if the seizures remain for 60
minutes. Cell death results from excessively increased
metabolic demands by continuously discharging neurons.
Areas of brain, which are most vulnerable to damage, are
hippocampus, amygdala, cerebellum, middle cortical
area, and thalamus. There is venous congestion, small
petechial hemorrhages, and cerebral edema.
There is lactic acidosis, an alteration in the blood-brain
barrier, raised intracranial pressure and fever due to
There are raised concentrations of calcium, arachidonic
acid, and prostaglandins, which cause cell death.
There is dysfunction of the autonomic nervous system
causing hypotension and shock
It is a medical emergency and requires
The main goals of the treatment of status
epilepticus are to:
1. Maintain adequate vital functions with
prevention of systemic complications.
2. Terminate the seizure activity safely and
quickly while minimizing treatment
3. Evaluate and treat any underlying cause
e.g., hypoglycemia, and meningitis
Airway: The highest priority is ensuring airway
patency. Maintain oral airway. Intubation may be
Breathing: Give oxygen to prevent hypoxia.
Circulation: Assess pulse, blood pressure.
Support with IV fluids. Monitor vital signs.
Measure serum glucose by finger prick.
Check body temperature. Lowering body
temperature is very important. Higher body
temperature increases the neuronal discharges
and the tissue damage associated with status
If vomiting occurs, turn the face to side and lower
Venous access should be established as quickly
Blood is drawn for immediate complete blood
count and measurement of
electrolytes, glucose, calcium, and magnesium
concentrations, toxic screen and levels of
anticonvulsant medications if the child is already
receiving therapy for seizures.
The initial stabilization phase of patient with
status epilepticus is usually accomplished within
the first 10 minutes after presentation to the
emergency department. Specific anticonvulsant
therapy is then started
If finger prick sample indicates blood glucose < 50
mg/dl, treatment is initiated for hypoglycemia (2-4 ml/kg
of 25 % dextrose; 0.5-l.Og/kg).
A benzodiazepine is the first drug used because of its
rapid onset of action.
Because the half-life of diazepam is very slow, it must be
followed immediately by. phenytoin. Dose is 20 mg/kg IV
in normal saline
If seizure activity continues for another 5-6
minutes, give 1 ml/kg sodium bicarbonate to treat
If status does not stop within 10 minutes the
total dose of phenytoin being given
phenobarbitone is the next drug.
If status is not responsive to a benzodiazepine
followed first by phenytoin and then by
phenobarbitone, the patient will require further
therapy as given below.
Paraldehyde 0.3 ml/kg PR mixed with equal
amount of mineral oil in a glass syringe.
Valproic acid 40-60 mg/kg/dose
Lidocaine 1-2 mg/kg IV up to 50 - 100 mg bolus over 2-4
minutes followed, if effective, by 3-5 mg/kg/hour as
solution of 100-1000 mg in 250 ml 5% dextrose.
Halothane anesthesia is given by
anesthesiologist, titrated to suppression of discharges on
Note: When a drug is selected to be used, sufficient time
must be allowed for the drug to act before more of the
same medication or another medication is used. If a
single agent does not control the seizures, a second drug
may be needed. I/V and rectal administration are the
routes of choice.
Give maintenance drug therapy by phenytoin
(10 mg/kg/day) or phenobarbitone 5mg/kg/day).
LP should be deferred until the patient's vital
signs are stable and the convulsion has stopped.
If sepsis is felt to be likely, I/V antibiotics may be
given immediately without waiting to do the
A history of trauma, evidence of raised
intracranial pressure, focal neurologic
signs, unexplained loss of consciousness or
suspicion of cerebral herniation are indications
for CT scan.