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Childhood Seizures in ER :              ManagementBy   Dr. Hussein Abdeldayem, MD     Head & Professor of Pediatric Neurol...
Case•   A 6 yr boy is    hospitalized because    of rhythmic shaking of    all limbs with eye    deviation
ER/Seizures•    Seizure in children is one of the    most anxiety-provoking conditions    for parents and a coon reason ...
ER/Seizures (cont.)• Anti-epileptic drugs should not be routinely  initiated in the emergency department in  children whos...
Seizure ?Epilepsy ?
Seizure           : the involuntary clinical manifestation (S &/or S)            due to an abnormal and excessive excitat...
Epilepsy
EPILEPSY Number ???       More than one                  More than one                  More than one                   Mo...
ACUTESeizure is an Manifestation         ChronicEpilepsy is a     DISEASE
Is it Seizure?What is the type of seizure?How do u treat acute seizure?
PATHOGENESIS OF SEIZURES
Mechanisms of Seizures        • Defective balance between excitatory and          inhibitory neurotransmission          +V...
Mechanisms of Seizures        • Defective balance between excitatory and          inhibitory neurotransmission            ...
classification• Aetiology• CP• EEG
EPILEPSY                 Aetiology      1985                   2010•   Idiopathic           •   Genetic•   Symptomatic    ...
Aetiology # Age•   Before age 2: Developmental defects, birth    injuries, CNS infections and metabolic    disorders• Ages...
General                         Activity2-Classification according to EEG findings                         Focal          ...
Classification according to EEG findings           Generalized                 Focal      Focal with                      ...
Pediatric Seizures                     Seizure Type Classification                  3- Clinically (ILAE 1981) GENERALIZED...
Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresTonic-clonic
Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresClonic
Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresTonic
Generalize Spike WaveDischarge
Which type of seizure is this ?   Generalized   Generalized     Seizures    Seizures Absence   VPA, ETX, LMT
Absence seizures and EEG
EEG: Absence SeizureEEG: classic 3/sec spike-and-wave especially with HV
Which type of seizure is this ?      Generalized      Generalized        Seizures       Seizures      Myoclonic
Which type of seizure is this ?     Generalized     Generalized       Seizures      Seizures     Atonic
Generalized Seizures                Generalized Seizures   Tonic   Clonic Tonic-clonic                       VALPROICAbsen...
Which type of seizure is this ?          (focal)           simple            Motor
EEG: Simple focal Seizure
EEG: Focal changes
Simple Partial (Focal) Seizures MotorSensoryautonomic psychic
Which type of seizure is this ?          Partial (Focal)         Complex partial            Complex Partial Seizure.flv
Partial (Focal) SeizuresSimple         Complex       2ry Generalization                Carbamazepine
Febrile Convulsions FC             DeFinition• Age : between 6 months and <6 years of  age• with fever > 38 ํํC ( rectal t...
Precipitating factors:
1. BodyPrecipitating factors:                            Temperature:                         •   Temperature ≥ 38 〬      ...
2. Infections & FC:•   VIRAL : UTRI, otitis media, roseola    infantum•   Bacterial: gastoeneritis,    pneumonia, UTI•   P...
3. Genetic Factors:      •   Positive family history for febrile seizures.      •  In most cases the disorder appears poly...
ClassifiCation of fC• Simple (typical) FC• Complex (atypical) FC
simple fC                          Complex fC• Constitute 80-85% of       •   Constitute 15 – 20% of FCs    FCs1- generali...
Which type of seizure is this ?Infantile Spasms      ACTH                                  S Zaher IS.3gp         VPA     ...
EEG finding:hypsarrhythmias
NEONATAL CONVULSIONS                  Subtle1- APNEA           2- eye
NEONATAL CONVULSIONS       Subtle     3- oral
NEONATAL CONVULSIONS       Subtle4- UL           5- LL
History (9)• First• Last• Frequency              • Aura              • Ictal              • Postictal                     ...
Practical PointsDURATION OF TREATMENT 2 years from last attack Withdraw over 3 months
VPA   GENERALIZED FITS       PARTIAL FITS
GENERALIZED FITSCBZ    PARTIAL FITS
Depakine               (Valproate)• 20 – 60 mg/kg/d• Twice*• FormsOral with dropperOral with spoon200 mg tablets500 mg chr...
Tegretol                   (Carbamazepine)• 10 – 20 mg/kg/d*• Twice• FormsOral (100 mg/5ml)200 mg tablets200 mg CR tablets...
Question for ALL• For my pediatric epileptic patients, well  controlled seizures are mostly through:A- MonotherapyB Polyth...
Seizures in E D
Case• A 6 yr boy is hospitalized because of  rhythmic shaking of all limbs with eye  deviation
• prolonged seizures may result in neuronal  injury, cell death, or both, and this  becomes most pronounced after half hou...
Status Epilepticus• 30*** minutes of continuous seizure  without regaining consciousness• Two or more Seizures with Failur...
Practical SE• If a seizure continues for more than 5  minutes  or• the patient has 2 or more generalized  tonic-clonic sei...
Practical Status epilepticusGeneralized convulsive status epilepticus  involves at least one of the following:• Tonic-clon...
Handlingof the active   seizure Stay calm andmanage effectively
Never restrain the child or place anything in the mouth
Treatment• ABCDs• Specific treatment*
ABCDs             •   Airway             •   Breathing             •   Circulation             •   Drugs*Initial studies i...
Lorazepam (ativan) 0.1 mg/kgDiazepam    0.3 mg/kg* PR diazepam       0.5 mg/kg
• In infants less than 24 mo of age,  intravenous pyridoxine (100–200 mg)  should be considered.
Rectal Diazepam*• The absorption of oral diazepam is slow  (1-2 hours) and variable.• Intramuscular diazepam has similar  ...
Rectal Diazepam*• Intravenous and rectal diazepam both stop  seizures in more than 80% of cases within  10-15 minutes     ...
Rectal Diazepam               • Use IV ampoules (10mg/2ml) or gel               • Use Insulin syringes*               • Re...
3
The following statements areeither true or false• Rectal diazepam is the treatment of choice  for status epilepticus.     ...
Timed treatment    •   0 – 5 min ABCD*    •   5 -10 min BZD IV x2    •   10-20 min DPH or PB IV    •   20-30 min PB or DPH...
Give the Diagnosis
Seizure pretenders•• Paroxysmal nonepileptic disorders that  may be mistaken for seizures   include syncope, breath holdin...
Thank you
Case (cont.)• You are called to the bedside and after 5   minutes, these movements have not   stopped.• Options for your n...
childhood  seizures and epilepsy for medical students
childhood  seizures and epilepsy for medical students
childhood  seizures and epilepsy for medical students
childhood  seizures and epilepsy for medical students
childhood  seizures and epilepsy for medical students
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childhood seizures and epilepsy for medical students

a lecture about childhood seizures and epilepsy
target: Medical student, Family medicine physicians, GP

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childhood seizures and epilepsy for medical students

  1. 1. Childhood Seizures in ER : ManagementBy Dr. Hussein Abdeldayem, MD Head & Professor of Pediatric Neurology Unit Faculty of medicine, Alex University
  2. 2. Case• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation
  3. 3. ER/Seizures• Seizure in children is one of the most anxiety-provoking conditions for parents and a coon reason for emergency department visits, especially if the seizure is of new- onset or the child is not on anti- epileptic medication
  4. 4. ER/Seizures (cont.)• Anti-epileptic drugs should not be routinely initiated in the emergency department in children whose seizures have resolved
  5. 5. Seizure ?Epilepsy ?
  6. 6. Seizure  : the involuntary clinical manifestation (S &/or S) due to an abnormal and excessive excitation and synchronization of a population of cortical neurons 
  7. 7. Epilepsy
  8. 8. EPILEPSY Number ??? More than one More than one More than one More than one Time onset?? day apart day apart ? FC, ? tetany unprovocative unprovocative
  9. 9. ACUTESeizure is an Manifestation ChronicEpilepsy is a DISEASE
  10. 10. Is it Seizure?What is the type of seizure?How do u treat acute seizure?
  11. 11. PATHOGENESIS OF SEIZURES
  12. 12. Mechanisms of Seizures • Defective balance between excitatory and inhibitory neurotransmission +VE -VE
  13. 13. Mechanisms of Seizures • Defective balance between excitatory and inhibitory neurotransmission + +VE - -VE
  14. 14. classification• Aetiology• CP• EEG
  15. 15. EPILEPSY Aetiology 1985 2010• Idiopathic • Genetic• Symptomatic • Structural (acquired)* (Acquired) • Unknown• cryptogenic * More in neonates and infancts
  16. 16. Aetiology # Age• Before age 2: Developmental defects, birth injuries, CNS infections and metabolic disorders• Ages 2 to 14: Idiopathic (genetic) seizure* disorders• Adults: Cerebral trauma, withdrawal, genetic GTC tumors, strokes, and unknown cause (in 50%) Childhood Absence• The elderly: Tumors and strokes
  17. 17. General Activity2-Classification according to EEG findings Focal Activity
  18. 18. Classification according to EEG findings Generalized Focal Focal with 2ry G Both Cerebral Only a part of a Hemispheres hemisphere Loss of Consciousness No loss of consciousness MRI Treated by Valproate Treated by Carbamazipine
  19. 19. Pediatric Seizures Seizure Type Classification 3- Clinically (ILAE 1981) GENERALIZED  FOCAL (PARTIAL)1- Involves both cerebral 1- involve one hemispheres hemisphere2- Loss consciousness 2- NO Loss of consciousness2- EEG: generalized 3- EEG: focal activity3- no aura 4- ± aura ASK MRI ± MRI Partial (focal) with Partial (focal) with secondary generalization secondary generalization
  20. 20. Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresTonic-clonic
  21. 21. Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresClonic
  22. 22. Which type of seizure is this ?Generalized SeizuresGeneralized SeizuresTonic
  23. 23. Generalize Spike WaveDischarge
  24. 24. Which type of seizure is this ? Generalized Generalized Seizures Seizures Absence VPA, ETX, LMT
  25. 25. Absence seizures and EEG
  26. 26. EEG: Absence SeizureEEG: classic 3/sec spike-and-wave especially with HV
  27. 27. Which type of seizure is this ? Generalized Generalized Seizures Seizures  Myoclonic
  28. 28. Which type of seizure is this ? Generalized Generalized Seizures Seizures Atonic
  29. 29. Generalized Seizures Generalized Seizures Tonic Clonic Tonic-clonic VALPROICAbsence ACID MyoclonicAtonic Mixed
  30. 30. Which type of seizure is this ? (focal) simple Motor
  31. 31. EEG: Simple focal Seizure
  32. 32. EEG: Focal changes
  33. 33. Simple Partial (Focal) Seizures MotorSensoryautonomic psychic
  34. 34. Which type of seizure is this ? Partial (Focal) Complex partial Complex Partial Seizure.flv
  35. 35. Partial (Focal) SeizuresSimple Complex 2ry Generalization Carbamazepine
  36. 36. Febrile Convulsions FC DeFinition• Age : between 6 months and <6 years of age• with fever > 38 ํํC ( rectal temperature)• but without evidence of intracranial infection and no history of prior afebrile convulsion
  37. 37. Precipitating factors:
  38. 38. 1. BodyPrecipitating factors: Temperature: • Temperature ≥ 38 〬 C • FC occur during 1st 24 hrs of the febrile illness • Depends on the rapidity of the rise rather than the temperature itself
  39. 39. 2. Infections & FC:• VIRAL : UTRI, otitis media, roseola infantum• Bacterial: gastoeneritis, pneumonia, UTI• Post-Vaccinational: pertussis & measles vaccination
  40. 40. 3. Genetic Factors: • Positive family history for febrile seizures. • In most cases the disorder appears polygenic. I n some families the disorder is inherited as an autosomal domina • Multiple single genes causing the disorder have been identified, FEB 1, 2, 3, 4, 5, 6, and 7 genes on chromosomes: • 8q13-q21 • 19p13.3 • 2q24 • 5q14-q15 • 6q22-24 • 18p11.2 • 21q22.
  41. 41. ClassifiCation of fC• Simple (typical) FC• Complex (atypical) FC
  42. 42. simple fC Complex fC• Constitute 80-85% of • Constitute 15 – 20% of FCs FCs1- generalized tonic- 1-focal seizure manifestations clonic motor activity2- less than 15 minutes 2-prolonged seizure activity with rapid return of exceeding 15 minutes consciousness. 3- recurring more than once3- not recurring more within 24 hrs than once within 24hrs 4- postictal neurological4-no postictal abnormalities neurological abnormalities5- normal CNS child 5- abn CNS : as CP No EEGNo EEG EEG EEGNO AEDNO AED AED AED
  43. 43. Which type of seizure is this ?Infantile Spasms ACTH S Zaher IS.3gp VPA CZP VGB
  44. 44. EEG finding:hypsarrhythmias
  45. 45. NEONATAL CONVULSIONS Subtle1- APNEA 2- eye
  46. 46. NEONATAL CONVULSIONS Subtle 3- oral
  47. 47. NEONATAL CONVULSIONS Subtle4- UL 5- LL
  48. 48. History (9)• First• Last• Frequency • Aura • Ictal • Postictal • duration • Investigation • Treatment
  49. 49. Practical PointsDURATION OF TREATMENT 2 years from last attack Withdraw over 3 months
  50. 50. VPA GENERALIZED FITS PARTIAL FITS
  51. 51. GENERALIZED FITSCBZ PARTIAL FITS
  52. 52. Depakine (Valproate)• 20 – 60 mg/kg/d• Twice*• FormsOral with dropperOral with spoon200 mg tablets500 mg chrono tablets• Follow up of:Serum drug level (peak)Serum drug level (trough)SGOT, SGPT, PT
  53. 53. Tegretol (Carbamazepine)• 10 – 20 mg/kg/d*• Twice• FormsOral (100 mg/5ml)200 mg tablets200 mg CR tablets400 mg CR tablets• Follow up of:Serum drug level (peak)Serum drug level (trough)Blood CBC
  54. 54. Question for ALL• For my pediatric epileptic patients, well controlled seizures are mostly through:A- MonotherapyB Polytherapy (2 drugs)C- Polytherapy (3 or more drugs)D- Other methods (?)
  55. 55. Seizures in E D
  56. 56. Case• A 6 yr boy is hospitalized because of rhythmic shaking of all limbs with eye deviation
  57. 57. • prolonged seizures may result in neuronal injury, cell death, or both, and this becomes most pronounced after half hour or more of continuous seizure activity• the earlier the therapeutic intervention, the more likely one can terminate the seizure
  58. 58. Status Epilepticus• 30*** minutes of continuous seizure without regaining consciousness• Two or more Seizures with Failure to regain consciousness Between Seizures (serial status)
  59. 59. Practical SE• If a seizure continues for more than 5 minutes or• the patient has 2 or more generalized tonic-clonic seizures within 1 hour, Aggressive management is warranted as these patients progress rapidly to status epilepticus
  60. 60. Practical Status epilepticusGeneralized convulsive status epilepticus involves at least one of the following:• Tonic-clonic seizure activity lasting > 5 to 10 min• ≥ 2 seizures between which patients do not fully regain consciousness
  61. 61. Handlingof the active seizure Stay calm andmanage effectively
  62. 62. Never restrain the child or place anything in the mouth
  63. 63. Treatment• ABCDs• Specific treatment*
  64. 64. ABCDs • Airway • Breathing • Circulation • Drugs*Initial studies include glucose, serum chemistries (most importantlysodium, magnesium, calcium, phosphate, BUN), arterial blood gas,AED levels (if applicable), CBC
  65. 65. Lorazepam (ativan) 0.1 mg/kgDiazepam 0.3 mg/kg* PR diazepam 0.5 mg/kg
  66. 66. • In infants less than 24 mo of age, intravenous pyridoxine (100–200 mg) should be considered.
  67. 67. Rectal Diazepam*• The absorption of oral diazepam is slow (1-2 hours) and variable.• Intramuscular diazepam has similar absorption problems, is painful and may cause muscle necrosis.• Suppositories have slow and variable absorption rates and are not recommended in an emergency.Rectal administration of the intravenous form of diazepam
  68. 68. Rectal Diazepam*• Intravenous and rectal diazepam both stop seizures in more than 80% of cases within 10-15 minutes Less Resp Depression Less BP Depression Less CNS Depression Prolonged action
  69. 69. Rectal Diazepam • Use IV ampoules (10mg/2ml) or gel • Use Insulin syringes* • Rectal administration (use lubricant) Dose: 0.5 MG/KG max: 10 mg LubricationDiazepam adsorbs to plastic and thus needs to be stored in glass
  70. 70. 3
  71. 71. The following statements areeither true or false• Rectal diazepam is the treatment of choice for status epilepticus. False• 2. Oil in water emulsions of injectable diazepam are inappropriate for rectal administration. True
  72. 72. Timed treatment • 0 – 5 min ABCD* • 5 -10 min BZD IV x2 • 10-20 min DPH or PB IV • 20-30 min PB or DPH IV • >30 min midazolam IV continuous infusion** • 40–60 min ICU, anesthesia, EEG
  73. 73. Give the Diagnosis
  74. 74. Seizure pretenders•• Paroxysmal nonepileptic disorders that may be mistaken for seizures include syncope, breath holding spells, sleep disorders, migraine headaches, apparent life threatening events (ALTE), and pseudoseizures
  75. 75. Thank you
  76. 76. Case (cont.)• You are called to the bedside and after 5 minutes, these movements have not stopped.• Options for your next course of action are:1- continue to wait for the spell to subside2- administration of IV diazepam3- administration of IV phenytoin4- administration of IV phenobarbitone

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a lecture about childhood seizures and epilepsy target: Medical student, Family medicine physicians, GP

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