BASIC CONCEPT ON SEIZURES AND THEIR MANAGEMENT

1. PEDIATRIC SEIZURES AND MANAGEMENT
PRESENTER: BIMENYIMANA Phocas, Medical student DOC 3, UR
Supervisor: MISAGO Gerard, RESIDENT, pediatrics

2. Introduction
• A seizure is a change in movement, attention or level of awareness
that is sustained or repetitive and occurs as a result of abnormal
neuronal discharges within the brain.
• Due to immaturity of children’s brain, seizures are more but seizures
are tend to disappear as the child grows

3. Epidemiology
• About 5% of all children will have at least 1 seizure by the
age of 15 with half of those episodes being febrile seizure.
• The prevalence of epilepsy is two to three times higher in
Sub-Saharan Africa than in industrialized countries
• The incidence is high in PRETERM neonates (2 fold), VLBW( 4
fold) compared to TERM neonates
• Seizures are common in neonatal period than any other time
in life.
• The commonest cause of seizures in children is a febrile
convulsion

4. 4
ETIOLOGY
Past perinatal conditions Infections Poisoning
• congenital infection
• hypoxic-ischaemic
damage
• trauma
• cerebral haemorrhage or
thrombosis
• cerebral malformation or
degeneration
• meningitis
• encephalitis
• brain abscess
• febrile convulsion
• Cerebral malaia
• accidental ingestion of
medicines
• medicine or drug withdrawal
ex: buspirone, alcohol, lead
poisoning
Metabolic conditions Systemic disorders Primary cerebral causes
• hypoglycaemia
• hypocalcaemia
• hypomagnesaemia
• hyponatraemia
• hypernatraemia
• inborn errors of metabolism
• vasculitis
• hypertensive
encephalopathy
• uraemia (renal failure)
• hyperammonaemia
(liver failure)
• head trauma
• haemorrhage
• thrombosis
• genetic/familial
(syndromic)
• tumour

5. Seizures: Pathophysiology:
Sustained partial depolarization in a group of neurons excitability
sudden depolarization in response to stimuli
conduction to surrounding cells, distant synaptically connected cells &
subcortical neurons dissemination loss of consciousness

6. CLASSIFICATION OF SEISURES
 Partial (focal) Seizures
• Simple partial (consciousness retained)
• Complex partial (consciousness impaired)
Generalized seizures
• Absence
• Myoclonic
• Clonic
• Tonic
• Tonic-clonic
• atonic
Epileptic spasms

7. FEBRILE SEIZURES
• Febrile seizures are convulsions in infants and children triggered by a
fever in the absence of CNS infection.
• Febrile seizures affect 4–5% of children aged 6 months to 6 years.
These occur in association with a high fever, typically above 38.5°C
(101.3°F), although some believe the rate of change in body
temperature is more provoking than the absolute temperature in
febrile seizures.
• There is often a positive family history of febrile seizures in other
family members.

8. Symptoms and Signs
Elements that are highly suggestive of true seizure activity
include:
• Lateralized tongue-biting (high specificity)
• Flickering eye-lids
• Dilated pupils with blank stare
• Lip smacking
• Increased heart rate and blood pressure during event
• Post-ictal phase

9. Seizures mimics (Differentials)
• Tremors: distal, rhythmic, equal amplitude, no loss of
consciousness
• Breath holding spells: always after crying, sequence of
events important
• Syncope: after prolonged standing/emotional upset,
gradual loss of consciousness, slow pulse, pallor,
sweating, improves in supine/head down position
• Pseudoseizures: seen in adolescents, never hurts
herself, eye closed, bicycling leg movements

10. MANAGEMENT, it’s an EMERGENCY
Initial steps:
• Shift child to a safer place (away from water, fire..)
• Put him in left lateral position (to prevent aspiration)
• Roll a kerchief and keep between teeth, if possible
• Assess ABC
• Airway: clear the secretions
• Breathing: give O2 / bag and mask / intubation
• Circulation: Pulse/ BP/ CFT: IVF
• Check glucose during the seizure and blood pressure after the seizure
!

11. MANAGEMENT cont’d
Emergency therapy: Stop the convulsions with fast
acting Benzodiazepines: Diazepam , Lorazepam or
Midazolam
• Diazepam: PR; 0.5 mg/kg
• Lorazepam: Longer duration of action; (0.05 mg/kg)
• Midazolam: by any route: IM/Nasal/Buccal (0.1mg/kg)

12. MANAGEMENT cont’d
• Even 5 minutes after the 1st dose of benzodiazepines, if
convulsions do not stop:
Give 2nd dose of Benzodiazepines
Start long acting drugs IV Phenytoin; 15-20 mg/kg
• At 10 min: 3rd dose of Benzodiazepines
• At 15 min: 4th dose of Benzodiazepines
• Then plan Investigations
• etiology will determine further management

14. Other tips on management!
• Rectal diazepam for use at home if patients have a recurrent
prolonged seizure in the future may be useful.
• Treatment should include identifying and treating the underlying
etiology.
• In a first episode seizure – assess for traumatic causes, CNS infections,
hypoglycemia or electrolyte abnormalities, toxic ingestions; among
other causes.
• Chronic anti seizures should not easily be considered due to theis side
effects.

15. INVESTIGATIONS
• Blood glucose: Always consider hypoglycemia as a primary or
aggravating cause of any seizure,
• Blood samples for malaria parasites
• Serum electrolytes ( Na, K, Ca, Mg)
• FBC, Urea and electrolytes
• hemoculture if suspected meningitis
• Urinalysis
• Lumbar puncture for CSF analysis
• Fundoscopy
• CT scan/MRI of the brain (if suspected intracranial mass, trauma)
• EEG( gold standard)

16. PROGNOSIS
• Focal-clonic seizures carry the best prognosis.
• Myoclonic seizures carry the worst prognosis in terms of
neurodevelopmental outcome and seizure recurrence.
• Seizures due to SAH (sub arachnoid hemorrhage) and late
onset hypocalcemia carry best prognosis in terms of long term
neurodevelopmental outcome.
• Seizures related to hypoglycemia, cerebral malformations and
meningitis have adverse outcome.

17. COMPLICATIONS
• Burns
• Aspiration
• Tongue biting
• Status epilepticus
• Hypoxia
• Severe brain damage (if prolonged convulsions)
• Cerebral palsy

18. EDUCATION
• Seizures do not hurt/damage brain if short – after 30 minutes there is
some evidence of damage
• During seizure turn over to side, nothing in mouth, make sure
nothing in environment can hurt child
• Water safety – shower, don’t bathe. Do not swim without someone
big enough to pull you out
• Don’t lock doors
• If older than 16y – ask about driving

19. References
• Loddenkemper, T., & Goodkin, H. (2011). Treatment of Pediatric
Status Epilepticus. In H. S. Singer (Ed.), Pediatric Neurology. In Current
Treatment Options in Neurology. Springer Science + Business Media.
DOI 10.1007/s11940-011-0148-3
• https://www.uptodate.com/contents/seizures-and-epilepsy-in-
children-classification-etiology-and-clinical-features#H7
• Wilfong, A. Treatment of seizures and epileptic syndromes in children.
In UpToDate., Nordii, D (Ed), UpToDate, Waltham, MA.

20. END
QUESTIONS AND SUPPLEMENTS ALLOWED!!