childhood seizures and epilepsy for medical students

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

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  • Children with  seizures are often referred to the  emergency department where they are typically evaluated by a physician with limited knowledge of pediatric epileptology and undergo a costly and extensive work-up that contributes little to the final decision
  • 1 in every 10 persons will experience a seizure at some time in their lifetime. 1 in every 100 persons will experience epilepsy resulting from excessive and abnormal discharge of cortical neurons
  • 1 in every 10 persons will experience a seizure at some time in their lifetime. 1 in every 100 persons will experience epilepsy resulting from excessive and abnormal discharge of cortical neurons
  • This question should be answered by every doctor in the meeting. Get the % of each answer, for me About 70% of cases with mono, 20% of poly 2 and 10% of more than 2 no other lines
  • SE could be terminated in 80% of patients who received “firstline” anticonvulsant medication within 30 min of onset. If first-line medication was started 2 h after onset, however, only 40% of patients responded
  • Serial seizures: 2 or more fits with regain of consciousness in between
  • The previous definition of > 30-min duration was revised to encourage more prompt identification and treatment. Untreated generalized seizures lasting > 60 min may result in permanent brain damage; longer-lasting seizures may be fatal. Heart rate and temperature increase
  • Keep calm and Reassure care giver
  • 1- lateral position and raise legs 2-Loosen clothing around neck and body 3- Ensure area around child is clear and safe
  • * > 5 min
  • 50 ml G50% B6 for infancy S spine Toxicology study ( blood and urine)
  • Lorazepam longer action and less resp depression 4mg/1ml Midazolam : IV, IM , intranasal, buccal, rectal DZP ; Iv, rectal (gel of solution and not suppositories) / diastat (rectal gel) not suppository diazepam acts to suppress seizures through an interaction with (gamma)-aminobutyric acid (GABA) receptors of the A-type (GABA A )
  • Although pyridoxine deficiency is a rare cause of SE, the diagnosis is made only by observing the EEG and clinical response to test doses
  • *use DZP gel (diastat) or IV solution Indication 1- severe epilepsy 2- with clusters (serial) seizures 3- prolonged seizures >5mg
  • Diazepam given rectally appears to be as effective as intravenous diazepam in terminating seizures. It may have advantages, including more prolonged action (20-30 minutes compared to 10-20 minutes), Time to peak plasma levels after rectal administration (about 5-10 minutes) is longer than after intravenous injection (1-3 minutes). This time difference may be important in status epilepticus where rapid seizure termination is necessary. It also possibly explains the lower incidence of respiratory depression experienced with rectal administration. The prolonged action after rectal administration may prevent seizure recurrence and allow more time to seek medical assistance.
  • Diazepam gel (diastat) or The breaking of ampoules (10 mg/2 mL) and the use of needles by non-medical carers can be difficult and dangerous. If it is necessary to dilute diazepam, it is important to dilute it correctly as certain volumes of normal saline or dextrose can result in the precipitation of diazepam. Some institutions like the Royal Children's Hospital in Melbourne prepare 25 mL bottles of a rectal solution (1 mg/mL) using 50% propylene glycol in water. This is easy to use and does not expire for one year. 3  Diazepam adsorbs to plastic and thus needs to be stored in glass. There are anecdotal reports of using diazepam oral mixture rectally, but its efficacy is not proven and thus cannot be recommended. Oil in water emulsions of injectable diazepam (e.g. Diazemuls) are slowly absorbed rectally and thus are inappropriate to use. A lubricated and suitably soft rectal tube is necessary as there are reports of hard plastic nozzles damaging the rectum. It is recommended that the tube or syringe is introduced only 4-5 cm into the rectum. Theoretically, administration of drugs higher into the rectum may result in greater first-pass metabolism, but clinically this is of minimal importance with rectal diazepam.
  • If possible, infants and toddlers should be placed prone for rectal diazepam to be administered. Older children should be positioned on their side, in the recovery position. After administration, keep the child in the same position and hold the buttocks together for a few minutes to limit leakage from the rectum.
  • 2- Oil in water emulsions of injectable diazepam (e.g. Diazemuls) are slowly absorbed rectally and thus are inappropriate to use.
  • *Diagnose; give O2, ABCs with frequent vital sign monitoring;obtain iv access; begin EKG monitoring; draw blood fo CBC, sodium, glucose, magnesium, calcium, phosphate,LFTs, AED levels, ABG, toxicology screen. Treat with thiamine 100 mg iv with 50 mL of D50 iv. ** propofol
  • 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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