pediatric convulsion

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pediatric convulsion

  1. 1. convulsions in children Prepared by: ANCY ANTO M.Sc. Nursing
  2. 2. History...  3000 yrs ago ......Babylonians wrote about the symptoms and causes of epilepsy  caused by demons attacking the person  The word epilepsy is derived from the Greek word for "attack’’
  3. 3. Patron of epilepsy.........   St.valentine
  4. 4. World epilepsy day National epilepsy day November 17
  5. 5. Did you know that:  Epilepsy is not a form of mental illness  Epilepsy can begin at any age from birth to 99+  Epilepsy can & does affect memory and learning.  NOTHING should be put in the mouth of a person having a seizure
  6. 6.  Medication does not stop all seizures .  Epilepsy is not contagious  The tongue cannot be swallowed during a seizure  Most seizures are not medical emergencies
  7. 7. Seizures...  It is a transient occurrence of signs and / or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain  A sudden paroxysmal electrical discharge from the CNS resulting in involuntary motor, sensory or autonomic disturbances with or without alteration in sensorium
  8. 8. Epilepsy....  Is a disorder of the brain characterised by an enduring predisposition to generate seizures & by the neurological cognitive, psychological & social consequences.
  9. 9. Epileptic syndrome..  Is a disorder that manifests one or more specific types and a specific age of onset and a specific prognosis.
  10. 10. Disorders mimicking seizures...  Jitteriness  Benign neonatal sleep myoclonus  Breath holding spells  Shuddering attacks  Syncopal attacks  Night terror  pseudo seizures
  11. 11. Provoked vs. Unprovoked seizures..  Provoked = occurs during the course of acute illness  Common causes  Febrile seizures  Metabolic events (b. sugar <36mg/dl)  Acute CNS infections  Drug intoxification  Head trauma
  12. 12. Incidence  72-80 / 1lak under 9 yrs of age  46-83 / 1lak under 14 yrs of age  Prevalence  Seizure disorders: 360/100,000 (India, Saha SP 2003).  350/1lak in India  Greater in neonatal period
  13. 13. Classification of Epileptic Seizures.  Partial seizures:  Simple partial (consciousness retained) Motor Sensory Autonomic Psychic  Complex partial (consciousness impaired) Simple partial, followed by impaired consciousness Consciousness impaired at onset  Partial seizures with secondary generalization
  14. 14.  Generalized seizures  Absences  Typical  Atypical  Generalized tonic clonic  Tonic  Clonic  Myoclonic  Atonic  Infantile spasms  Unclassified seizures
  15. 15. ILAE classification Self limited  Focal  Generalised Continuous Classification of epilepsy syndromes •Idiopathic-focal & general •Familial •Symptomatic •reflex
  16. 16. Common causes Infection to the central nervous system 1. Acquired bacterial meningitis  tuberculus meningitis  aseptic  encephalitis  cerebral malaria 2. Intrauterine infections
  17. 17. Post infectious or post vaccinal encephalopathy  Pertussis vaccination  Pan encephalitis  Post measles encephalopathy  Chickenpox encephalopathy  Disseminated encephalomyeolopathy
  18. 18. Metabolic causes  Dehydration  Dyselectrolytemia  Acidosis/ alkalosis  Hypocalcaemia/ hypomagnesaemia  Inborn errors of metabolism
  19. 19. Space occupying lesions in the brain  Neoplasm  Brain abscess  Tuberculoma  Cysticercosis
  20. 20. Vascular  Arterio venous malformations  Intracranial thrombosis/ haemorrhage  Coagulopathies Congenital malformations Migration defects
  21. 21. Miscellaneous  Birth trauma  Birth asphyxia  Heat stroke  Brain swelling  Poisoning  Lead encephalopathy  Breath holding spells  Gray matter degeneration
  22. 22. Drugs and poisons  Toxic doses of phenothiazine  Salicylate  Diphenylhydantoin  Carbon monoxide
  23. 23. Causes Early neonatal period Neonatal period 1m - 3 yrs Birth asphyxia Obstructed labour IVH Hypoglycaemia IEM Hypocalcaemia Kernicterus Developmental malformations Meningitis Metabolic errors Febrile convulsions Neurologic infections Metabolic causes Lesions drugs
  24. 24. Mechanisms of seizure 1. Underlying aetiology 2. Epileptogenesis 3. Excitability 4. Neuronal injury after prolonged febrile & afebrile status epilepticus
  25. 25. Neuron – action potential
  26. 26. Basic mechanisms of epileptogenesis
  27. 27. Neurophysiology and neurochemistry Epileptogenic neurons + disinhibition + circuit PDS trigger Ca channel (Mg) synchronization Opens sp. K+ channel Hyperpolarisation
  28. 28. Hyperpolarisation Disappear depolarisation seizure
  29. 29. Kindling  Process by which brief trans of electrical stimuli are repeatedly delivered at appropriate intervals to a susceptible area of brain.  Prolonged generalised seizure
  30. 30. Factors determine focal – generalised  Excitability of epileptic neurone  The ease with which the electric discharge can be propagated from focus  Threshold of brain stem for disseminating an electrical discharge
  31. 31. Excitatory & inhibitory neurotransmitters  Glutamate & aspartate – Excitatory neurotransmitters Induces Ca + ion current Depolarisation seizure
  32. 32. Inhibitory neurotransmitters GABA Hyperpolarisation GABA receptors are coupled with Cl- channel stabilises cell in resting potential  Pyridoxine deficiency  Adenosine- inhibit the release of excitatory neurotransmitters
  33. 33. Catecholamine's & indolamines  ↓ in nor epinephrine -↑ seizure susceptibility  ↑ in nor epinephrine- ↓ seizure severity
  34. 34. Biochemical alterations induced by seizure
  35. 35. epilepsy syncope Precipitating factors Occurrence Onset Duration Jerking limbs Facial colour Perspiration Post ictal recovery Post ictal confusion EEG & prolactin Rare Awake , sleep Abrupt 60-90 sec Yes Flushed Hot, sweaty Slow Common Positive Common Awake Gradual 10-15 sec Occasional Pale Cold, clammy Rapid Uncommon Negative
  36. 36. Partial seizures.  Simple partial Localised motor symptoms Somatosensory, psychic, autonomic symptoms  Manifestations - aversive seizure- eyes and head turn away from focus & loss of consciousness - rolandic seizure - tonic–clonic movements involving face, salivation, arrested speech
  37. 37.  Jacksonian march - Sequential progression of Clonic movements
  38. 38. Simple partial seizures with sensory signs..  Numbness  Tingling  Pricking  Paresthesia/ pain originating in one area  Visual sensations  Motor phenomena – posturing / hypertonia - Uncommon < 8yrs
  39. 39. Complex partial seizures(psychomotor seizures)  3yrs – adolescence  Characterised by - Period of altered behaviour - Amnesia - Inability to respond to environment - Impaired consciousness during event - Drowsiness / sleep - Confusion & amnesia
  40. 40. aura  odd or pleasant odours  Auditory or visual hallucinations  Ill defined feelings (de javu)  Strong feelings of fear and anxiety  In small children - emission of cry - attempt to run
  41. 41. Patterns of motor behaviour  Stereotypic  May suddenly cease activity , appear dazed stare into space  Confused & apathetic  Become limp or stiff  automatisms  Post ictal confusion
  42. 42.  Exhibit oropharyngeal activities –smacking chewing , drooling etc  Rarely exhibit – temper tantrums or rage
  43. 43. Generalised seizures  Tonic clonic seizures (grandmal ) - Most common - Occur without warning Tonic phase clonic phase post ictal phase
  44. 44. Tonic phase  10- 20 sec  Eyes roll upward  Immediate loss of consciousness  Stiffness  Contraction of entire body  Arms flexed  Legs, head & neck flexed
  45. 45.  May utter a peculiar cry  Apnoeic  Increased salivation  Loss of swallowing reflex  If standing, falls to floor or ground
  46. 46. Clonic phase  30 sec  Violent jerking movements  Foams at mouth  Incontinent of urine and faeces
  47. 47. Post ictal state  Appears relaxed  Remain semiconscious  May awake in few minutes  Confused for several hours  Poor coordination  Mild impairment in fine motor movements
  48. 48.  Visual & speech difficulties  Vomit or complain of severe headache  Usually sleeps for several hours  Feels tired  No recollection of event
  49. 49. Absence seizures (petit mal/ lapses)  4-12 years of age  common in girls than boys  Ceases at puberty  Brief / no loss of consciousness  No alteration in muscle tone  May go unrecognised  Abrupt in onset
  50. 50. Manifestations:  Brief loss of consciousness  Without aura  5-10 sec  Slight loss of muscle tone  Minor movements  No incontinence  Amnesia  Need reorientation
  51. 51. Atonic & akinetic seizures (drop attacks )  2-5 yrs  Sudden momentary loss of muscle tone & postural control  Recurrent frequently Manifestation : - Loss of tone causing child to fall down
  52. 52. Myoclonic seizures  Seizure episodes  Sudden brief contractions of a muscle  No post ictal state  May / not LOC
  53. 53. Infantile spasms  Infantile myoclonus / massive spasms / hypsarrhythmia / salaam episodes / Infantile myoclonic spasms  6- 8 months of life  Twice common in boys  Numerous without post ictal drowsiness
  54. 54. Manifestations  Series of sudden muscular contractons  Head flexed arms extended & legs drawn up  Eyes rolling  Preceded / followed by cry  May / not LOC  Flushing / pallor / cyanosis
  55. 55.  Jack-knife seizure – sudden dropping forward of the head & neck with trunk flexed forward  Single momentary shock like contractions
  56. 56. Comparison of simple, complex partial & absence seizure Clinical features Simple complex Absence Age of onset Any age Uncommon before 3 yrs Uncommon before 3 yrs Freq /day Variable 1- 2 times Multiple Duration < 30 sec >60 sec <10 sec Aura May be sole manifestation Frequently never Impaired consciousness Never always Always Automatisms never frequent frequent
  57. 57. Clinical features Simple complex Absence Clonic movements Frequent Occasional Occasional Post ictal impairment Rare Frequent Never Mental disorientation Rare Common Unusual
  58. 58. Video game related epilepsy  Flicker frequency of video games  Type – generalised , simple / complex / absence  Treatment – abstain from video games  Factors – screen brightness, sleep deprivation, fatigue, fever, short distance from screen
  59. 59. Epilepsy syndromes  The Major Benign Partial Syndromes 1. Benign Rolandic Epilepsy - Male preponderance 60% - Onset 2 - 13 years (peak: 9-10 years) - Older children- motor & somatosensory symptoms, usually nocturnal.
  60. 60.  Younger children- Hemiclonic / GTCS (especially at night).  Rx: None if seizures are mild and rare.  Most AEDs very effective.  Evolution: Recovery before 15 - 16 years.
  61. 61. Benign Occipital Epilepsy  Frequency- rare  Genetic 37%, migraine 17%  Male = female  Onset 2 - 17 years (peak:7 - 8 years)
  62. 62.  Initial visual symptoms, often followed by a hemiclonic seizure or by automatism  Postictal migrainous cephalgia in a quarter of the cases.  Rx: Most AEDs with control in 60%.  Recovery by end of adolescence.
  63. 63. The Major Primary Generalized Syndromes Childhood Absence Epilepsy (True Petit Mal Epilepsy)  Frequency 8%  Genetic predisposition- strong 20%  Female preponderance 75%  Onset 3 - 12 years (peak: 6 - 7 years)  Very frequent simple absences.
  64. 64.  Rx: VPA or ESM with control in 70 - 80%. Evolution: Remission- 95%. - Rare persistence of absences only- 6%. - GTCS during adolescence or later- 40%.
  65. 65. Juvenile Myoclonic Epilepsy (JME)  Frequency 5%  Genetic predisposition- strong >25%  Male = female  Onset: 8-26 years (peak: 16 - 17)  Myoclonus , GTCS often also occur, occasionally absence.  Rx: VPA with control in 60 - 100%  Evolution: Rarely remits (<10%)
  66. 66. Grand Mal on Awakening (GMA)  Genetic predisposition- strong >10%  Male > female  Onset 6-24 (peak: puberty)  GTS exclusively or predoninantly (90%)  Myoclonic or absence may occur.  Rx: VPA with control in 60 - 100%  Evolution: Rarely remits (<20%)
  67. 67. The Major Secondary Generalized Syndromes Infantile Spasms (West Syndrome) Lennox Gastaut Syndrome (LGS)  Frequency 3 - 10%  Genetic predisposition- no  Male preponderance  Onset 1 - 8 years (peak: 3 - 5 years)
  68. 68.  Poor prognosis in most cases  Tonic, atypical absence, drop attacks, other generalized or partial seizures.  Rx: VPA,rarely with complete control.  persisting seizures.
  69. 69. DIAGNOSTIC EVALUATION  History collection  Physical examination  Laboratory investigations - Serum glucose & calcium levels • Lumbar puncture – Ist febrile seizures protein content – increased
  70. 70. Imaging studies:  CT  MRI- structural lesions  PET-demonstrate perfusion,O2 & glucose intake  SPECT scan- perfusion in ictal & inter ictal state  Cerebral angiography  Magneto encephalography  Telemetry
  71. 71. Electroencephalogram Electric activity of brain.  Fast activity – beta rhythm(14 - 20 Hz)  Alpha rhythm – 8 -13 Hz  Theta rhythm – 4 - 7 Hz  Slow rhythm- 1 - 3 Hz
  72. 72. Absence seizure
  73. 73. Abnormalities.  Slow/ abnormal rhythm-generalised ,localised or lateralised to one side thus helps to anatomic lesions  Spikes  Sharp waves  Poly spikes  Slow waves (hypsarrhythmia)
  74. 74. Tests consider in the evaluation of patients with seizures Type Test Comments Simple partial Complex partial GTC Absences MRI MRI MRI None required Rule out structural lesions Rule out structural lesions Rule out structural lesions
  75. 75. Management of child with seizures Goals: 1. Ensure adequate vitals & oxygenation 2. Terminate seizure activity 3. Prevent seizure recurrence 4. Establish the diagnosis & treat the underlying
  76. 76. steps  Step I – confirm diagnosis  Step II – establish seizure type & syndrome  Step III – evaluate the need for treatment  Step IV – select AED  Step V – start monotherapy (start slow go slow policy)  Step VI – switch to another monotherapy add on therapy
  77. 77. Treatment of a newly diagnosed case of epilepsy Newly diagnosed case Ist monotherarpy seizure therapy IInd monotherapy/ combination therapy seizure free Intractable epilepsy Combination therapy ketogenic diet , VNS
  78. 78. Choice of AED Seizure First line second line partial CBZ, PHT, SVA , PB OXC, LTG, TPM 2nd gen GTCS SVA, ESM, CZP, CLB LTG , TPM , LEV GTCS SVA, CBZ, PHT, PB TPM, LTG, OXC, LEV Absence SVA, CZP, CLB LTG , TPM , LEV Myoclonic SVA LTG , TPM , LEV Atonic / tonic SVA CBZ, CLB , NTZ, LTG, TPM mixed SVA
  79. 79. ILAE GUIDELINE FOR DRUG LEVEL MONITORING  Check compliance once or twice YEARLY  Suspect toxicity after each AED change DURATION:  Withdrawal – if seizure free for 2 YEARS  Gradually over 6-12 wks
  80. 80. Ketogenic diet  A very strict diet that involves fluid restriction, high fat and low carbohydrate + protein intake.  The goal: alter the body’s fuel source from glucose to fat.  The basis of the diet – fasting  The encounter with a faith healer
  81. 81.  Duration – 2yrs
  82. 82. Sample Meals:  Meal 1:  melted butter  heavy whipping cream  chicken  apple  sugar free Jell-O
  83. 83. Problems that may arise:  Low blood sugar  Lethargy  Nausea  Vomiting  Elevated cholesterol  Kidney stones  Constipation  Weight loss or gain  Dehydration  Cheating
  84. 84. Vagus nerve stimulation  >12 years  50% reduction in seizures
  85. 85. Types of surgery 1. Resection Removal of the area causing the seizures 2. Disconnection Corpus callosotomy Multiple subpial transections 3.Hemispherectomy
  86. 86. procedure Type Temporal lobectomy nonTemporal lobectomy Corpus callostomy Hemispherectomy Simple/ complex partial Partial Partial, tonic ,clonic Unilateral , partial , hemiparesis
  87. 87. Nursing management  Seizure precautions  Relieving anxiety  Managing treatment  Providing family support & education
  88. 88. Febrile seizures  Occurrence of seizure activity in neurologically healthy infants & children between 6 months & 5 yrs of age associated with fever >38c without evidence of intracranial infection & with no history of prior afebrile seizures
  89. 89.  Common in 18- 22 months  Provoked seizures  Causes: - Infections of middle ear - URTI - Urinary tract & GI infections
  90. 90. Types  Simple febrile seizures: - 85% - Generalised seizures - Lasting less than 15 min - No post ictal neurologic abnormalities
  91. 91.  Complex febrile seizures - Recurrent within 24 hrs  Febrile status - A seizure with duration of 30 min - Without regaining consciousness interictally
  92. 92. Risk factors  Age <18 months  Family history  Shorter duration Recurrence 75% within 1 yr Risk of subsequent epilepsy – 2- 2.5 %
  93. 93. Diagnostic evaluation  History  Serum electrolytes – calcium , magnesium  Blood glucose LUMBAR PUNCTURE  abnormal neurological examination  Ongoing seizure
  94. 94. Management  During the seizure - Manage as for any other acute seizure - Should hospitalise o Lethargy o Complex features o Unclear follow up
  95. 95. Long term management  Primary goal – to prevent recurrences  Antipyretics – to reduce fever INTERMITTENT PROPHYLAXIS  Diazepam – 0.3 – 0.5 mg/ kg orally / rectally  clobazem - 1mg /kg / day
  96. 96. Continuous prophylaxis  Indications : - Recurrent complex seizures - Abnormal neurodevelopment - Positive family history  Sodium valproate is preferred
  97. 97. Status epilepticus  A seizure that persists for a sufficient length of time / is repeated frequently enough that recovery between attacks does not occur Early status established status Epilepticus Epilepticus
  98. 98. A condition characterised by an epileptic seizure that is sufficiently prolonged or repeated at sufficiently brief intervals so as to produce an unvarying and enduring epileptic condition (dictionary of epilepsy )
  99. 99. Etiology  Recurrent neonatal seizures  Traumatic subarachnoid haemorrhage  HIE  IEM
  100. 100. Classification  Generalised status epilepticus  Partial status epilepticus  Refractory status epilepticus  Super refractory status epilepticus
  101. 101. Generalised status epilepticus  Convulsive seizures 1. Tonic clonic 2. Tonic 3. Clonic 4. Myoclonic  Non convulsive
  102. 102. Refractory status epilepticus  Persistent seizure beyond 120 min  Despite of therapy with benzodiazepine, phenytoin, phenobarbitone or valproate  Treatment : - Midazolam - Thiopentone - Magnesium - Ketogenic diet
  103. 103. Intractable epilepsy  It is defined as an at least one seizure every 2 months for the first 5 years of treatment & subsequently as at least one seizure per year with failure of at least 3 Ist line AEDs  Rx: surgery  Ketogenic diet  VNS
  104. 104. Misconceptions about childhood epilepsy  Children with epilepsy are brain injured  Has mental handicaps  Only SE will harm child's brain  An EEG will determine if child has epilepsy  Abnormal EEG -↑ AED dose
  105. 105.  Child has twitches of legs & arms while asleep. Are these seizures ?  Blood level AED ↑ - change the dose ?  AED – only way of treatment  Surgery – after a attempting all AED  Life will never be the same
  106. 106. Nursing diagnosis  Risk for injury related to CNS dysfunction & inability to control self secondary to the type of seizure.  Risk for aspiration & ineffective breathing pattern related to impaired motor activity, LOC.  Risk for injury related to impaired consciousness & automatisms
  107. 107.  Anxiety / fear related to child having life threatening seizure activity  Ineffective tissue perfusion  Interrupted family processes  Self esteem disturbances

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