Pediatric Seizures
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Pediatric Seizures
- 1. M a x A n g e l o G . T e r r e n a l Seizures and Status Epilepticus in Children
- 2. What is a SEIZURE?
- 3. paroxysmal involuntary motor activity and/or changes in behavior caused by synchronous firing of a group of neurons in the brain
- 6. Children less than 5 years old
- 7. Children less than 5 years old excitatory > inhibitory
- 8. excitatory > inhibitory Children less than 5 years oldPeriod of Vulnerability
- 9. cognitive impairment and behavioral abnormalitiesCNS disease or anticonvulsants?
- 10. A single prolonged seizure has been shown to damage the brain 30
- 12. EPIDEMIOLOGY
- 13. seizure disorders are the most common neurologic disorders of childhood
- 14. 4 to 10% suffer at least one seizure in the first 16 years
- 15. 30% who have a first afebrile seizure develop epilepsy
- 16. 3% cumulative lifetime incidence of epilepsy
- 17. FEBRILE SEIZURES 30% recur after first episode
- 18. FEBRILE SEIZURES 50% recur after 2 or more of infants <1 y/o at onset
- 19. FEBRILE SEIZURES 2-7% proceed to epilepsy
- 25. DIAGNOSIS
- 26. seizure or not?
- 29. syncope Preceded by • dizziness • weakness • tunnel vision • pallor • diaphoresis Associated with • brief loss of consciousnes s • quick recovery with no postictal state
- 30. seizures cyanosis tongue biting rhythmic motor activity incontinence slow recovery and postictal state
- 37. vs
- 38.
- 40. convulsive generalized both hemispheres motor activity on both sides
- 41. nonconvulsive generalized both hemispheres no motor activity recognizable by EEG
- 49. simple febrile seizures or complex febrile seizures
- 50. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 51. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 52. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 53. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 54. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 55. simple febrile seizuresgeneralized tonic-clonic <15 minutes > fever of 380C 6 months to 5 years of age once in a 24-hour period
- 56. complex febrile seizuresfocal >15 minutes < 6 months to > 5 years of age recur within a 24-hour period
- 57. complex febrile seizuresfocal >15 minutes < 6 months to > 5 years of age recur within a 24-hour period
- 58. complex febrile seizuresfocal >15 minutes < 6 months to > 5 years of age recur within a 24-hour period
- 59. complex febrile seizuresfocal >15 minutes < 6 months to > 5 years of age recur within a 24-hour period
- 60. complex febrile seizuresfocal >15 minutes < 6 months to > 5 years of age recur within a 24-hour period
- 61. febrile seizures anticonvulsant therapy is not recommended for simple febrile seizures
- 62. STATUS EPILEPTICUS prolonged or recurrent >5 minutes without regaining consciousness
- 63. REFRACTORY STATUS EPILEPTICUS uncontrolled with 2 or more standard doses of treatment
- 64. MANAGEMENT
- 65. most seizures stop within 5 minutes and do not require medical treatment
- 66. Status Epilepticusseizure > 5 minutes or multiple seizures over a period of > 5 minutes
- 69. Oxygen support
- 71. Oxygen support IV access • Rapid bedside electrolyte level • Complete blood count • Full chemistry panel • Hepatic and renal studies • Anticonvulsant levels
- 72. intubate = clinical apnea and persistent hypoxia
- 74. blood gas concentration paralytic metabolic and respiratory Acidosis obscure assessment
- 77. FIRST LINE benzodiazepines bind to GABA receptors
- 79. benzodiazepines FIRST LINE Diazepam Lorazepam Midazolam Lorazepamfewer side effectslonger duration
- 80. Initial benzodiazepine treatment should be limited to 2 doses FIRST LINE
- 84. SECOND LINE phenobarbital bind to GABA receptors
- 86. SECOND LINE fosphenytoin > phenytoinprecipitate in an IV line hypotension cardiac arrhythmias
- 87. SECOND LINE fosphenytoin > phenytoinprecipitate in an IV line hypotension cardiac arrhythmias must be given slowly
- 89. SECOND LINE fosphenytoin < phenobarballergies to phenytoin with a febrile illness <2 years of age
- 93. hypoglycemia Glucose < 50 mg/dl 2 ml/kg 25% dextrose in water
- 94. hyponatremia Sodium < 135 mEq/L Seizures at < 120 mEq/dl 3% NaCl for active seizures
- 95. hypocalcemia 10% calcium gluconate 0.3 mL/kg slowly over 5 to 10 minutes
- 96. hypomagnesemia Mg < 1.5 mEq/L 50 mg/kg IV infused over 20 minutes
- 103. Philippine CPG first febrile seizure
- 104. lumbar puncture should be performed in all children below 18 months with a first simple febrile seizure Philippine CPG
- 105. children 18 months and older, lumbar puncture should be performed in the presence of clinical signs Philippine CPG
- 107. neuroimaging studies should not be routinely performed Philippine CPG
- 108. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures Philippine CPG
- 109. For a first simple febrile seizure the use of intermittent or continuous (phenobarbital or diazepam) is not recommended for the prevention of recurrent febrile seizures. Philippine CPG
- 110. Electroencephalogram should not be routinely requested Philippine CPG
- 111. Thank you
Editor's Notes
- paroxysmal involuntary motor activity and/or changes in behavior caused by synchronous firing of a group of neurons in the brain
- It a balance between 2 neurotransmitters, glutamate and GABA.
- A seizure’s electrical activity can be captured in an electroencephalogram (EEG). However, seizure activity is not always visible in an EEG, and the diagnosis of epilepsy is made clinically.
- Children less than 5 years old are most susceptible to seizure because of the immaturity of the nervous
- where excitatory activity predominates and inhibitory systems are undeveloped
- This is known as the period of vulnerability.
- children with epilepsy are at a significant risk for cognitive impairment and behavioral abnormalities. It is difficult to distinguish the relative contributions of the effect of the seizures from the underlying CNS disease and from the effect of anticonvulsants.
- A single prolonged seizure which lasts >30 minutes has been shown to damage the brain
- A single prolonged seizure (>30 minutes) has been shown to damage the brain, particularly the temporal lobes and hippocampus.
- Seizure disorders are the most common neurologic disorders of childhood; 4 to 10% of children suffer at least one seizure in the first 16 years of life. For epidemiologic purposes epilepsy is considered to be present when ≥2 unprovoked seizures occur in a time frame of >24 hr. The cumulative lifetime incidence of epilepsy is 3%, and more than half of the cases start in childhood. The annual prevalence is 0.5-1%. Thus, the occurrence of a single seizure or of febrile seizures does not necessarily imply the diagnosis of epilepsy.
- Seizure disorders are the most common neurologic disorders of childhood
- 4 to 10% of children suffer at least one seizure in the first 16 years of life
- Risk factors for occurrence of subsequent epilepsy. Neurodevelopmental abnormalities and focal complex seizures has the highest risk for developing epilepsy
- Tonic seizures are stiffening or straightening of the arms or legs clonic seizure activity is the repeated contraction and relaxation of muscles resulting in repeated jerking. Generalized tonic-clonic seizures involve the entire body and are analogous to generalized convulsive or grand mal seizures.
- Generalized tonic-clonic seizures involve the entire body and are analogous to generalized convulsive or grand mal seizures. Aura phase of a tonic-clonic seizure may manifest as light headedness, dizziness, confusion or hallucinations. Followed by the tonic phase and the clonic phase.
- Table 129-2 outlines a number of clinical signs and symptoms of seizures.
- One of the most important issues is to decide whether or not a seizure has occurred.
- Taking a good history, conducting a thorough examination, and recognizing the subtle differences between seizures and other conditions that may masquerade as seizures are essential to making the correct diagnosis.
- Most of the conditions masquerading as seizures are benign, and thus minimal evaluation is needed. Breath-holding is cyanosis provoked by upsetting or scolding and it usually used for secondary gain. Cataplexy is a transient loss of mucle tone and Narcolepsy is an attack of irrepressible sleep with cataplexy Vasovagal attacks are caused by decreased blood flow to the brain. If the diagnosis is still unclear, EEG and outpatient neurologic consultation may be warranted.
- Syncope is the most common condition that may be mistaken for seizures
- Syncope is commonly preceded by dizziness, weakness, tunnel vision, pallor, and diaphoresis (presyncopal aura). It is also associated with a brief loss of consciousness and a quick recovery with no postictal state.
- Seizures, however, may be preceded by an aura but usually do not have a provoking factor noted before the event. Seizures are associated with cyanosis, tongue biting, rhythmic motor activity, incontinence, and a slow recovery and postictal state.
- General approach to evaluation of pediatric seizures
- Children with known seizure disorder may be non-compliant of may have outgrown medication dose.
- Seizures may also manifest after a head trauma causing intracranial injury
- Brain tumors, Atrioventricular Malformations, Stroke and abusive head trauma seizures can be identified by doing a neurological examination. Febrile seizures are patients with fever with unremarkable focal neurologic exam
- Febrile seizures are patients with fever with unremarkable focal neurologic exam
- Electrolyte abnormalities especially hypoglycemia, hyponatremia, hypocalcemia and hypomagnesemia may manifest as seizure as well.
- Seizures may be generalized or partial.
- a seizure starting as partial can become generalized and vice versa.
- For generalized seizure
- Generalized seizure can be convulsive where it involves both hemispheres of the brain are involved and rhythmic motor stiffening and/or shaking affects both sides of the body.
- A nonconvulsive generalized seizure also involves both hemispheres of the brain but manifests no motor activity—seizure activity is recognizable only on EEG. During both convulsive and nonconvulsive generalized seizures, the patient loses consciousness and a postictal period follows.
- Other generalized seizures are
- An absence seizure manifests as an episode of staring without a postictal state. In atonic seizures a patient suddenly lacks muscle tone and drops to the ground. Myoclonic seizures occur when a patient has a sudden, brief total body jerking movement.
- An absence seizure manifests as an episode of staring without a postictal state. In atonic seizures a patient suddenly lacks muscle tone and drops to the ground. Myoclonic seizures occur when a patient has a sudden, brief total body jerking movement.
- An absence seizure manifests as an episode of staring without a postictal state. In atonic seizures a patient suddenly lacks muscle tone and drops to the ground. Myoclonic seizures occur when a patient has a sudden, brief total body jerking movement.
- Partial seizures are focal, involving only part of the brain, with manifestations correlating with the affected area.
- Partial seizures are focal, involving only part of the brain, with manifestations correlating with the affected area. In a simple partial seizure, the patient is awake.
- Complex partial seizure is a focal seizure in which the patient is unconscious.
- Febrile seizures are categorized as simple or complex
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- The definition of a simple febrile seizure is a generalized tonic-clonic seizure lasting <15 minutes with a fever ≥38°C (≥100.4°F) in a child 6 months to 5 years of age that occurs only once in a 24-hour period
- Complex febrile seizures are defined as seizures with fever that last >15 minutes, that recur within a 24-hour period, that are focal, or that occur in children <6 months or >5 years of age without any signs of serious infection.
- Complex febrile seizures are defined as seizures with fever that last >15 minutes, that recur within a 24-hour period, that are focal, or that occur in children <6 months or >5 years of age without any signs of serious infection.
- Complex febrile seizures are defined as seizures with fever that last >15 minutes, that recur within a 24-hour period, that are focal, or that occur in children <6 months or >5 years of age without any signs of serious infection.
- Complex febrile seizures are defined as seizures with fever that last >15 minutes, that recur within a 24-hour period, that are focal, or that occur in children <6 months or >5 years of age without any signs of serious infection.
- Complex febrile seizures are defined as seizures with fever that last >15 minutes, that recur within a 24-hour period, that are focal, or that occur in children <6 months or >5 years of age without any signs of serious infection.
- Anticonvulsant therapy is not recommended for simple febrile seizures. Side effects of the medications outweigh the minor risks of seizure recurrence. Although antipyretics are indicated in children with fever, there is no evidence that antipyretics can prevent subsequent febrile seizures.
- Status epilepticus is a “prolonged” seizure or recurrent seizures lasting >5 minutes without the patient’s regaining consciousness. Rapid cessation of status epilepticus is important to prevent irreversible neuronal damage.
- Refractory status epilepticus is a prolonged seizure that cannot be controlled with two or more standard doses of treatment.
- Most seizures stop within 5 minutes and do not require medical treatment. Status epilepticus (seizure activity lasting for >5 minutes or multiple seizures over a period of >5 minutes) is more responsive to medications when treated early, and medical treatment becomes less effective with time.
- Status epilepticus is more responsive to medications when treated early, and medical treatment becomes less effective with time.
- Children may have been treated at home or by EMS personnel. Prehospital first-line treatment in most cases is a benzodiazepine However, not all benzodiazepines or routes are available in the prehospital setting, and establishing IV access can be difficult.
- Benzodiazepines may be given IO, intranasally, PR, or buccally if an IV is difficult to place. Rectal diazepam is one “rescue” medication commonly used at home and by EMS personnel. The advantage is that no refrigeration or IV line is needed. The disadvantage is its short half-life and the need for rectal administration. Midazolam, also an effective rescue medication, can be safely given intranasally using a mucosal atomization device Midazolam can also be given buccally. Lorazepam is not generally used in the prehospital setting because of its need for refrigeration and delivery via an IV line. There is some evidence that intranasal lorazepam may be used to treat status epilepticus using a MADR.
- Administer oxygen by face mask and institute continuous pulse oximetry.
- IV access is important for administering most medications
- Order a complete blood count (CBC), full chemistry panel, hepatic and renal studies, and anticonvulsant levels, if appropriate, when an IV is placed. Other studies may be needed depending upon the suspected underlying cause of seizures. Consider CNS infection in the child with fever and status epilepticus.
- The decision to intubate is clinical. Intubate for apnea and persistent hypoxia.
- Determining blood gas concentrations and the use of paralytic with intubation are not recommended
- because the seizure itself causes a metabolic and respiratory acidosis and the use of paralytic may obscure the ability to assess ongoing seizure activity
- continuous EEG monitoring should be arranged for intubated patients with status epilepticus
- Benzodiazepines are the initial treatment for status epilepticus. They are initially preferred over other medications because of their rapid onset of action
- They act by binding to GABA receptors, which are inhibitory.
- IV lorazepam is generally preferred over other benzodiazepines if an IV line is available
- Because of its longer duration of action and some evidence that it has fewer side effects than the other benzodiazepines.
- If two doses did not stop the seizure, additional doses are unlikely to be successful and it would increase the risk for respiratory depression. That is why initial benzo treatment should be limited to 2 doses
- This is lifted from the textbook.
- Phenytoin and fosphenytoin, its prodrug, inhibit neurons from firing by stabilizing sodium channels and reducing neuronal calcium uptake.
- Phenobarbital like Benzos, bind to GABA receptors
- Fosphenytoin is preferred over phenytoin, because its administration is safer.
- Phenytoin may precipitate in an IV line, causing significant injury to the surrounding tissue.
- IV phenytoin may also result in hypotension or cardiac arrhythmias and must be given slowly.
- Fosphenytoin is usually the preferred second-line treatment over phenobarbital, mainly because it differs from the benzodiazepines. Benzodiazepines and phenobarbital have the same mechanism of action (both bind GABA receptors).
- Phenobarbital is preferred over phenytoin or fosphenytoin in children who have allergies to fosphenytoin or phenytoin, present with a febrile illness, or are <2 years of age. Side effects of phenobarbital are sedation and cardiorespiratory depression, which may be amplified by benzodiazepines.
- Valproic acid and Levetiracetam are used in status epilepticus and is effective for partial and generalized seizures. However, valproic acid should be used with caution in children at risk for metabolic disease, because in rare cases it may cause hepatic failure in these children. It inhibits a calcium-dependent neurotransmitter and affects GABA receptors. Levetiracetam is eliminated solely via renal excretion and has no liver metabolism.
- Most laboratory results are not immediately available when treating status epilepticus. can cause seizures. Seizures caused by low electrolyte levels are poorly responsive to medication but do respond to replacement electrolyte therapy.
- Hypoglycemia is defined as a glucose level of <50 milligrams/dL regardless of whether symptoms exist. There are multiple causes of hypoglycemia, but the most common cause in children is decreased intake of glucose. Seizures can occur with hypoglycemia, so glucose level should be measured in all patients presenting with seizures
- Excessive water drinking can lead to hyponatremia (<135 mEq/L). Hyponatremia is most commonly seen in infants <6 months of Age and sometimes in athletes. Babies who drink several bottles of water a day or who drink dilute infant formula are at risk for hyponatremia. Athletes can also suffer from water intoxication. If a patient is actively experiencing seizure, the treatment of choice is 3% NaCl. An infusion of 20 mL/kg of 0.9% NaCl should be started immediately for patients in status epilepticus if delivery of 3% NaCl is delayed. 3% NaCl (513 mEq/1000 mL): Na deficit in total mEq = [(weight in kg) × (130 – serum Na level) × 0.6] over 20 minutes or 3% NaCl: 4 to 6 mL/kg over 20 minutes If there is no seizure activity but the sodium level is below 120 mEq/L, 4 to 6 mL/kg of 3% NaCl or 20 mL/kg of normal saline can be given over an hour. The sodium level should be rechecked after the bolus to see if a second bolus is necessary
- Hypocalcemia is caused by abnormal calcium absorption, excretion, or distribution and can also cause seizures Hypocalcemia is more common in neonates and young infants and may be associated with congenital anomalies such as DiGeorge syndrome.
- Hypomagnesemia is defined as a serum magnesium level of <1.5 mEq/L. There are many causes of low magnesium level, but the major causes are GI and renal losses (see Chapter 142, Fluid and Electrolyte Therapy in Infants and Children). Seizures due to hypomagnesemia are less common than those due to low levels of sodium, glucose, and calcium. The treatment is magnesium, 50 milligrams/kg IV infused over 20 minutes.
- After providing oxygen support, IV access must be obtained
- Benzodiazepines are used for initial treatment, preferably lorazepam
- To rule out the alternative diagnosis of meningitis
- For those children 18 months of age or older, lumbar puncture should be performed in the presence of clinical signs of meningitis such as meningeal signs and sensorial changes. Neuroimaging studies should not be routinely performed. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures. For a first simple febrile seizure, the use of intermittent (phenobarbital or diazepam) as well as continuous (phenobarbital or valproic acid) anticonvulsants is not recommended for the prevention of recurrent febrile seizures. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant their use in this benign disorder. Electroencephalogram should not be routinely requested.
- For those children 18 months of age or older, lumbar puncture should be performed in the presence of clinical signs of meningitis such as meningeal signs and sensorial changes. Neuroimaging studies should not be routinely performed. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures. For a first simple febrile seizure, the use of intermittent (phenobarbital or diazepam) as well as continuous (phenobarbital or valproic acid) anticonvulsants is not recommended for the prevention of recurrent febrile seizures. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant their use in this benign disorder. Electroencephalogram should not be routinely requested.
- In order to rule out the alternative diagnosis of meningitis, lumbar puncture should be performed in all children below 18 months with a first simple febrile seizure. For those children 18 months of age or older, lumbar puncture should be performed in the presence of clinical signs of meningitis such as meningeal signs and sensorial changes. Neuroimaging studies should not be routinely performed. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures. For a first simple febrile seizure, the use of intermittent (phenobarbital or diazepam) as well as continuous (phenobarbital or valproic acid) anticonvulsants is not recommended for the prevention of recurrent febrile seizures. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant their use in this benign disorder. Electroencephalogram should not be routinely requested.
- In order to rule out the alternative diagnosis of meningitis, lumbar puncture should be performed in all children below 18 months with a first simple febrile seizure. For those children 18 months of age or older, lumbar puncture should be performed in the presence of clinical signs of meningitis such as meningeal signs and sensorial changes. Neuroimaging studies should not be routinely performed. Antipyretic drugs are used to lower fever and should not be relied upon to prevent the recurrence of febrile seizures. For a first simple febrile seizure, the use of intermittent (phenobarbital or diazepam) as well as continuous (phenobarbital or valproic acid) anticonvulsants is not recommended for the prevention of recurrent febrile seizures. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant their use in this benign disorder. Electroencephalogram should not be routinely requested.
- For a first simple febrile seizure, the use of intermittent (phenobarbital or diazepam) as well as continuous (phenobarbital or valproic acid) anticonvulsants is not recommended for the prevention of recurrent febrile seizures. Although anticonvulsants can reduce the recurrence of febrile seizures, the adverse side effects of these drugs do not warrant their use in this benign disorder. Electroencephalogram should not be routinely requested.
- Electroencephalogram should not be routinely requested.