pediatric seizures

1. Seizure In children
Incidence,
assessessment and
management

2. Definition
• Seizure: abnormal electrical discharges from
brain resulting in abnormal involuntary,
paroxysmal, motor, sensory, autonomic or
sensorial activity
• Convulsion: seizure associated with motor
component
• Epilepsy: recurrent, episodic, paroxysmal,
involuntary clinical events associated with
abnormal electrical activity in brain
– 2 or more unprovoked seizures >24hrs apart

4. Causes of seizure
• Febrile seizure
• CNS infections
– Meningitis, encephalitis, TBM, cerebral malaria
– Intrauterine infection
• Post infectious/vaccine
– Post viral infection, pertusis vaccine, SSPE
• Metabolic
– Hypoglycemia, hyponatremia, hypomagnesemia, IEM
• ICSOL
– Brain abscess, tuberculoma, NCC, neoplasms
• Vascular
– ICH, thrombosis, AV malformations
• Drugs/poisons
• Epilepsy
• Miscellaneous
– Heat stroke, neurocutaneous syndromes, degenerative brain disease,
sequelae of birth trauma/asphyxia

5. History:
Complete description of seizure type
:myoclonic,generalized tonic clonic,absence
start of seizure, its spread, duration, loss of
consciousness,
post ictal weakness,confusion
 precipitating or triggering factors, average frequency
of attacks, response to previous medications
Developmental history , Family history, history of
neonatal or febrile seizures, previous brain injury, and
history of other neurologic or systemic disease,drug
abuse
Evaluation of first seizure

6. Evaluation of the first seizure
• During or shortly after seizure, an assessment of adequacy of
airways, breathing, cardiac function, and measurement of
temperature.
• To determine the potentially life-threatening conditions like
meningitis, encephalitis, sepsis, toxins ingestion, head trauma
• Drugs abuse
• Other associated findings to search:
– Head circumference, weight,
retinoscopy to look for papilledema, retinal hemorrhages
– rashes
Evaluation of first seizure

7. Definition
• Status epilepticus
Defined as continuous seizure activity lasting more than
30 min or 2 or more seizures in this duration without
gaining consciousness between them
Operational definition: Defined as continuous seizure
activity lasting more than 5 min or 2 or more seizures
in this duration without gaining consciousness between
them

8. PATHOPHYSIOLOGY
• OVERACTIVITY OF BRAIN CELLS DUE TO
TRIGGERING FACTORS
• INCREASED ELECTRICAL EXCITABILITY
• SEIZURE

9. Classification of Epilepsy
Generalized
• Grand mal epilepsy
(GTCS)
• Tonic
• Clonic
• Atonic
• Absence
• Myoclonic
Localized
• Simple partial
• Complex partial

10. Management
• Initial stabilization
• Termination of seizure
• Evaluation and treatment of underlying cause

11. Initial stabilization
 Keep in safe place :
If you see pt falling ,try to ease fall
Prevent injury by clearing the area around the person of anything hard or
sharp
Place soft clothes , folded jacket under his head.
Don’t restrain the patient
 Maintain Airway Patency:
• left lateral position
• clear secetions
• Don’t insert anything in mouth(eg spoon)
• Head tilt, chin lift , jaw thrust to prevent toungue fall
• Loosen tie ,clothing around the neck
• Remove artificial dentures if possible

12.  Breathing:
oxygen by mask
Intubation maybe required
 Circulation: iv access
iv fluids
send blood for investigations:
CBC,RFT,RBS,LFT,CALCIUM,MAGNESIUM
Termination of seizure: antiepileptic agents

13. Algorithm for management of status epilepticus
Time Drug treatment General measures Investigations
0 min IV Access available: Inj Lorazepam 0.1mg/kg/IV (Max 4mg)
OR Inj Midazolam 0.15-0.2mg/kg IV (Max 5mg)
IV Access not available: Buccal Midazolam 0.3mg/kg (Max
5mg) OR Per rectal Diazepam 0.5mg/kg (Max 10mg)
Inj Lorazepam 0.1 mg/kg IV (Max 4mg) OR Inj Midazolam-
0.15-0.2mg/kg IV (Max 5mg)
•Airway
•Breathing
•Circulation
•Establish IV
access
•Temperature
Glucose,
sodium,
potassium,
calcium,
magnesium
5 min •Oxygen inhalation
•Cardiorespiratory
monitoring: ECG,
BP, SPO2
Glucose
May consider:
CRP,
complete
blood
counts, AED
level,
Toxic screen,
BUN
10 min IV Phenytoin* 20 mg/kg (Max: 1000mg) in NS @ 1
mg/kg/min (Max 50 mg per min), OR
Inj Fosphenytoin 20 mg PE/ kg, Rate: 3 mg PE/kg/min
Repeat inj. Phenytoin 10 mg/kg / Inj Fosphenytoin 10 mg
PE/ kg, if no response to initial dose

14. Algorithm for management of status epilepticus
Time Drug treatment General
measures
Investigations
Refractory SE-
even after
10 min
of phenytoin/
fosphenytoin
administration
IV Valproate 20- 30 mg/kg-IV @ max 6
mg/kg/minute.
OR
IV Phenobarbitone 20 mg/kg in NS @ 1.5
mg/kg/min; Repeat 10 mg/kg if no response to
initial dose
Continue
monitoring as
above
Use
vasopressors, if
needed
Identify and
treat
medical
conditions
and electrolyte
disturbances
Consider:
•CT head
•LP- for CNS
infections
•EEG
Coma induction - seizure continues 10 min after completion of phenobarbitone infusion

15. Monitor vital parameters
After seizure: check
consciousness
Keep in recovery position
Evaluation and treatment of the
underlying cause:
CT/MRI head
Lumbar puncture
EEG

16. Refer if:
• Seizure for more than 5 min or repeated
seizure
• Patient unconscious
• Patient injured
• Cause of seizure is unknown
• Associated diseases
• Patient is aggressive
• Seizure occurred in water

17. Evaluation for underlying cause
• blood investigations:
CBC,RFT,LFT,CALCIUM,MAGNESIUM,BLOOD
SUGAR
• CT head
• EEG
• Lumbar puncture

18. Seizure d/d
• Jitteriness
• Night terrors
• Breath holding spells
• Syncope
• Migraine
• Pseudoseizures

19. SEIZURE VS HYSTERIA( pseudoseizure)
Clinical features Seizure pseudoseizure
Type Fixed pattern of seizure Changing pattern
Duration Shorter(less than 5 min) Longer (min -hours)
Tongue bite Present Absent
Gaze To one side Avoidant gaze
Place of occurance Anywhere and even while
at sleep
Seeks safe places,mostly in
crowd.never at night
Disease condition Neurological disorder Psychological disorder
Stress factor Absent present
Treatment t/t of cause Psychiatric counselling

20. Questions