Child with convulsion
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approach to a child with convulsion - differential diagnosis, how to diagnose each one of it and management.
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Child with convulsion
- 1. CHILD WITH CONVULSION FADZLINA ZS 082013100006
- 2. Learning outcome Seizures in childhood • Febrile seizure • Unprovoked seizure • Partial seizure • Generalized seizure • Mechanism of seizure • Treatment of epilepsy • Neonatal seizure • Status epilepticus • Conditions that mimics seizure
- 3. Seizure is a clinical event in which there is a sudden disturbance of neurological function caused by an abnormal or excessive neuronal discharge. Febrile convulsion is a seizure associated with fever in the absence of another cause and not due to intracranial infection from meningitis or encephalitis Epilepsy is recurrent seizures other than febrile convulsions in the absence of an acute cerebral insult.
- 4. Mechanism of seizure 1. Influence of excitatory glutamate-containing circuits 2. Neuronal death – develop excitable synapse 3. Immature brain 4. Genetic factors • Benign neonatal convulsion • Juvenile myoclonic epilepsy • Progressive myoclonic epilepsy
- 9. Condition that mimics seizure • Syncope • Breath holding spell • Aspiration/GERD • Psych – panic attack, day dreaming, ADHD • Conversion, pseudoseizures • Benign sleep myoclonus • Complex migraine • Motor tics
- 12. Approach to a child with seizure • Pre ictal – Any warning ? Abdomen pain, fear, unpleasant sensation – Asleep or awake – Trigger factor – Any fever? • Ictal – Responding during spell vs unconscious – Does the child remember the spell – Repetitive behaviours during spell – Body movements – part or all – Cyanosis – Incontinence – Duration – Gaze deviation, eye rolling History
- 13. • Post ictal – Drowsy/ Confused/Tired • Trauma • Previous history of seizure, febrile seizure • Development • Current medications (buspirone) • Family history of seizure/epilepsy
- 14. • Vitals, temperature • Height, weight, head circ. • CNS – signs of ICP, cranial nerves, motor, sensory, cerebellar, reflexes, • Signs of trauma • Skin exam – neurocutaneous marker • Sources of infection – ear, throat, abdomen, respiratory Physical examination
- 15. Blood investigation – Complete blood count, blood sugar, – Arterial blood gas – Electrolyte – Serum creatine kinase activity – Serum prolactin : increase in generalized and complex partial seizure. Not increase in absence and myoclonic – Rise in ACTH and cortisol : post ictal phase Investigation Urine - urinalysis
- 16. Lumbar puncture and CSF culture – Indication – Suspicion of meningitis or encephalitis – All HIV infected person Electroencephalography (EEG) – Diagnsosis and classified seizures
- 17. Neuroimaging MRI and CT scan of brain MRI FLAIR PET AND SPECT – Indication : • fixed focal deficit, • failure of seizure control with first line AED, • worsening of seizure
- 18. Investigation
- 19. Treatment First step – to ensure that the patient has a seizure disorder and not a condition that mimics epilepsy Second step – Choosing an anticonvulsant – Goals : to use only one drug with fewest possible side effect
- 23. Radical treatment In children with intractable seizures • Ketogenic (fat based) diets . Its mechanism of action is poorly understood. • Vagal nerve stimulation, stimulation of a wire implanted around the vagal nerve, may possibly be useful for focal seizures; trials are being conducted. • Surgery – temporal lobectomy for mesial temporal sclerosis but other procedures include hemispherectomy or hemispherotomy (does not involve hemisphere removal and problems with shifts in space) and focal resections
- 24. • Febrile convulsion are common • Recurrences likely • No evidence of deaths • If lasting >10min and not stopping • Rectal diazepam • Or immediately to the hospital • Information and advise sheet Advise and counselling
- 26. Status epilepticus Seizure lasting >30 min or repeated seizures for 30min without recovery of consciousness in between
- 29. Summary • Seizures are a behavioral change produced by an abnormal hypersynchronous neuronal discharge • In a febrile seizure – important to rule out CNS infection • In a first episode seizure – assess for traumatic causes, CNS infections, hypoglycemia or electrolyte abnormalities, toxic ingestions; among other causes
- 30. REFERENCES • Nelson Textbook of Pediatrics, 1st Edition • Ghai Essential Pediatrics, 8th Edition • Illustrated textbook of paediatrics by Tom Lissauer 3rd Edition • https://www.macpeds.com/documents/Approachto Seizures.pdf
Editor's Notes
- There is a broad differential diagnosis for children with paroxysmal disorders. Epilepsy is a clinical diagnosis based on the history from eyewitnesses and the child's own account. If available, videos of the seizures or suspected seizures can be of great help. The diagnostic question is whether the paroxysmal events are that of an epilepsy of childhood or one of the many conditions which mimic it (Fig. 27.1). The most common pitfall is that of a syncope leading to an anoxic (non-epileptic) tonic-clonic seizure. The key to the diagnosis lies in a detailed history, which, together with clinical examination, will determine the need for an EEG or other investigations
- Not all seizures require anti-epileptic drug therapy. This decision should be based on the seizure type, frequency and the social and educational consequences of the seizures against the possible unwanted effects of the drugs. Not all seizures require anti-epileptic drug therapy. Choose the appropriate drug for the seizure. Inappropriate antiepileptics may be detrimental, e.g. carbamazepine can make absence and myoclonic seizures worse. Monotherapy at the minimum dosage is the desired goal, although in practice several drugs may be required. All anti-epileptic drugs (AEDs) have potential unwanted effects in which should be discussed Patients with prolonged benzodiazepine, e.g. rectal diazepam or buccal midazolam. Anti-epileptic drug therapy can usually be discontinued after 2 years free of seizures.
- Surgery. Cessation of seizures and drug therapy may be achieved in some children whose clinical seizures are localised to a specific location in the brain as demonstrated on the EEG and functional imaging. The main procedure is temporal lobectomy for mesial temporal sclerosis but other procedures include hemispherectomy or hemispherotomy (does not involve hemisphere removal and problems with shifts in space) and focal resections. Detailed assessment is required to ensure that the benefits outweigh the risks.